Newton Wellesley Hospital

Previous single-center studies conducted in the United States in women with suspected preeclampsia indicated that serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio values of >38 measured on a widely available Elecsys immunoassay platform during the third trimester of pregnancy predicted the development of preeclampsia with severe features and adverse outcomes within 2 weeks of testing. This study aimed to validate the Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test for the prediction of preeclampsia with severe features in a United States population using the prospective Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification cohort that recruited women with a hypertensive disorder of pregnancy (gestational hypertension, chronic hypertension, de novo and superimposed preeclampsia) across 18 tertiary and community hospitals throughout the United States. We measured soluble fms-like tyrosine kinase 1-to-placental growth factor ratios using the Elecsys platform in archived serum samples from the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study that recruited hospitalized women with a hypertensive disorder of pregnancy between 23 0/7 and 34 6/7 weeks of gestation. The primary study outcome was prediction of preeclampsia with severe features within 2 weeks after testing. The secondary outcomes included a composite of adverse maternal and fetal/neonatal outcomes and prediction of delivery within 2 weeks. In the validation cohort of the Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification study (556 enrollments), the serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 67% positive predictive value (95% confidence interval, 61-73) and a 95% negative predictive value (95% confidence interval, 92-97) for the progression to preeclampsia with severe features within 2 weeks. Among women at <30 weeks of gestation (n=188), serum soluble fms-like tyrosine kinase 1-to-placental growth factor ratio at a cutoff value of >38 demonstrated a 78% positive predictive value (95% confidence interval, 68-86) and a 100% negative predictive value (95% confidence interval, 96-100) for the progression to preeclampsia with severe features within 2 weeks. The Elecsys soluble fms-like tyrosine kinase 1-to-placental growth factor ratio test performed better than standard-of-care clinical measures, with an area under the receiver operating characteristic curve of 0.92 (95% confidence interval, 0.89-0.90) for soluble fms-like tyrosine kinase 1-to-placental growth factor ratio vs <0.70 for standard-of-care tests, such as liver enzymes, platelet count, and serum creatinine (P<.001). Compared with women with a ratio of ≤38, those with a ratio of >38 had a higher risk of developing adverse maternal (relative risk, 4.9 [95% confidence interval, 2.6-9.9]; P<.001) and fetal/neonatal (relative risk, 3.2 [95% confidence interval, 2.6-4.0]; P<.001) outcomes and were more likely to deliver within 2 weeks (adjusted hazard ratio, 3.3 [95% confidence interval, 2.7-4.0]; P<.001). The soluble fms-like tyrosine kinase 1-to-placental growth factor ratio of >38 measured on the Elecsys platform predicted the development of preeclampsia with severe features, delivery, and adverse maternal and fetal/neonatal outcomes within 2 weeks of testing among preterm pregnant women hospitalized with a hypertensive disorder of pregnancy.

BACKGROUNDMedial dished (MD) liner designs for cruciate-retaining (CR) total knee arthroplasty (TKA) are a relatively novel development. MD tibial inserts have a more constraining medial side, which allows for more similar kinematics and function to a native knee.AIMTo evaluate the clinical results and patient-reported outcomes after CR TKA procedures utilizing a kinematically designed medial dish system.METHODSA multicenter, retrospective cohort review of 139 primary elective TKAs utilizing a kinematically designed CR Knee System (JOURNEY™ II CR MD; Smith and Nephew, Memphis, TN, United States) at three different institutions with a minimum of two years of follow-up. Demographic information, clinical outcomes, and patient-reported outcome measures were collected and analyzed.RESULTSWith up to 3.7 years from surgery, overall implant survivorship was 98.6%. There were significant postoperative increases in the average Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores (17.4 at 6 months, 26.1 points at two years or more, P < 0.001).CONCLUSIONThe combination of high implant survivorship and substantial improvements in patient-reported outcome measures suggests that the medial dish tibial insert represents a safe and effective option within TKA. Additional investigation is necessary to evaluate the long-term survivorship of this design.

Assessing the severity and clinical impact of syndesmotic injury, especially when subtle, remains among the most diagnostically challenging conditions in foot and ankle orthopaedics. The distal tibiofibular syndesmosis is a complex, three-dimensional (3D) joint critical to ankle stability, and substantial injury to its ligament complex-especially if undetected or undermanaged-can result in long-term functional impairment. Unfortunately, routine clinical and conventional imaging evaluations are often inconclusive, falling short of capturing the dynamic and subtle nature of syndesmotic instability. Moreover, while myriad techniques have been reported to assist with diagnosis, none have proven reliably effective in isolation nor superior to comparison with the patient's uninjured side. Currently, there exists no singular test that can reproducibly function as a binary endpoint for diagnosis, suggesting that the future of accurate diagnosis-particularly of subtle instability, which can occur in various planes-will require either a composite testing endpoint, more sensitive 3D imaging modalities supported by artificial intelligence databases, or both. As orthopaedic practice advances towards individualised, precision-based care, diagnostic modalities must evolve to better reflect functional anatomy and quantify pathology in multiple planes at once. Weight-bearing computed tomography (WBCT) has emerged as a transformative tool that enables high-resolution, comparative 3D assessment of the syndesmosis under physiological load. Cadaveric and clinical studies have demonstrated WBCT's high diagnostic accuracy, reproducibility and efficiency-especially when integrated with automated 3D volumetric analysis. Quantitative thresholds such as side-to-side 3D volume differences or lateral translation measurements provide robust criteria for instability. Since it has been demonstrated that these imaging techniques are more accurate when comparing the injured to the uninjured limb rather than using population norms, the contralateral side can serve as an internal reference-improving precision and reducing reliance on generalised values. New machine learning algorithms using WBCT now allow real-time, high-accuracy evaluation with almost immediate comparative results. As normative databases grow, these algorithms will improve, clarifying variations between a patient's two ankles. Standardised software can also reduce measurement errors still common with conventional assessments. Despite its advantages, WBCT adoption is limited by cost and integration challenges. Nonetheless, its expanding applications represent a shift in orthopaedic diagnostics towards more functional, individualised imaging.

Operative intervention with multimodal therapy, including systemic therapy and radiation, is routinely used in the curative-intent treatment of patients with pancreatic ductal adenocarcinoma (PDAC). Occasionally, patients are unable to undergo multimodal therapy. However, contemporary data on the benefit of operation alone for patients with resectable PDAC are limited. The National Cancer Database was queried for patients diagnosed with resectable (clinical stage II or less) PDAC between 2010 and 2016. Patients who underwent upfront resection without additional treatment were compared with those who refused operation, to determine the comparative role of isolated surgical intervention for PDAC. Propensity score matching was used to account for selection bias. A total of 2,391 (6.1%) underwent upfront curative-intent resection without further treatment and 485 (1.2%) refused recommended operation. Propensity matching resulted in 471 well-balanced pairs. In the surgery group, 30- and 90-day mortality was 7% (33) and 17% (81), respectively. Median overall survival (OS) was 14.09 months (95% CI 12.39 to 16.72) compared with 6.34 months (95% CI 5.72 to 6.9) in the no-treatment group (log rank test p < 0.001). Estimated 1-year OS rates were 56% (95% CI 51.7 to 60.8) vs 26% (95% CI 22.3 to 30.6), respectively. For patients who underwent operation with R0 resection, median OS was 17.87 months (95% CI 14.7 to 21.3) compared with 7.56 months (95% CI 6.5 to 11.5) for non-R0 resection (log rank test p < 0.001). This national study of patients with early-stage PDAC affirms that surgical resection, in the absence of multimodal therapy, is associated with improved outcomes compared with no resection. However, the association with improved survival is clinically annulled in the absence of a negative-margin resection.

Research data are not shared.

Radiographic measurement of patient-specific spinopelvic mobility is standard-of-care in total hip arthroplasty (THA). Current manual methods are time-consuming, subjective, and error-prone. This study utilized deep learning (DL) to classify functional positions and measure pelvic tilt (PT), sacral slope (SS) and lumbar lordotic angle (LLA). A DL pipeline integrating image classification, vertebra detection, and landmark detection was developed using data from an international joint registry, comprising 52,772 images for classification, 9,875 for object detection, and 25,249 for landmark detection. Performance was evaluated using area under the curve (AUC), F1 score, and mean absolute error (MAE). Accuracy was compared to annotations by three expert engineers and validated by two senior engineers and a surgeon. Radiographs were processed in 1.96 ± 0.04 s, achieving precision, recall, Receiver-operator-characteristic-AUC, and Precision-Recall-AUC metrics above 0.994. Anatomical landmark predictions resulted in errors of: PT: 1.6°±2.1°, SS: 3.3°±2.6°, LLA: 4.2°±3.2°. There was no significant difference in PT and LLA between expert engineers and the DL pipeline, and 0.5° difference in SS (p = 0.043). Clinical validation showed no difference in landmark rejection rates (p > 0.05). We developed and clinically validated a DL pipeline that accurately measures patient-specific spinopelvic mobility from lateral functional radiographs, providing a scalable method for routine characterization in THA patients.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-16824-6.

Value-based health care emphasizes streamlining costs and improving outcomes. We used time-driven activity-based costing and patient-reported outcome measures to perform a patient-level value analysis. We compared the cost and cost-effectiveness of unicompartmental knee arthroplasty (UKA) and primary total knee arthroplasty (TKA). We sourced cases from a prospectively maintained, multi-institutional arthroplasty registry. A total of 422 UKAs were matched 1:3 to 1,266 primary TKAs, on baseline characteristics. Revision, conversion, and robotic cases were excluded. Time-driven activity-based costing was used to calculate total procedure facility costs. Costs were converted from United States dollars to cost units (CUs) by dividing all costs by an undisclosed constant. Knee Osteoarthritis Outcome Score Physical Function Short-Form (KOOS-PS) scores were collected preoperatively and 1 year postoperatively. Value KOOS-PS was calculated for each patient. Value KOOS-PS was defined as the quotient of 1-year improvement in KOOS-PS and total procedure facility cost. Value KOOS-PS was converted to a scale with a maximum of 100. UKA had higher mean Value KOOS-PS than primary TKA (UKA: 18.3 vs. primary TKA: 15.8; P = 0.009). KOOS-PS scores were not the primary driver of differences in value, as the procedures did not differ significantly in 1-year change in KOOS-PS (UKA: +16.5 vs. primary TKA: +16.1; P = 0.641). Instead, substantial differences in costs drove the observed differences in value. Primary TKA facility costs were 20.3% more expensive than UKA (811 CUs vs. 674 CUs; P < 0.001). When only outpatient procedures were considered, outpatient primary TKA facility cost was 8.3% more expensive than outpatient UKA (720 CUs vs. 665 CUs; P < 0.001). UKA offers higher value that primary TKA, driven primarily by lower cost structure rather than differences in patient-reported outcomes. To maximize health care value, patients with single compartment disease should be treated with UKA, as they will have similar outcomes with reduced cost, as compared with primary TKA. Outpatient surgery can considerably-but not entirely-reduce the facility cost discrepancy between primary TKA and UKA.

Cutaneous squamous cell carcinoma (CSCC) risk stratification is central to management, and physicians rely on tumor staging systems to estimate risk. The Brigham and Women's Hospital (BWH) T staging system predicts risk based on 4 tumor risk factors (RFs). However, stage is not precisely associated with the number of RFs, as BWH stage T2b includes CSCCs with 2 and 3 RFs. To determine how RF number is associated with the risk of recurrence, metastasis, and disease-related death. This retrospective multination cohort study of CSCCs diagnosed between October 1, 1991, and July 19, 2023, was conducted at 12 centers in the US (10), Spain (1), and Brazil (1). Invasive CSCCs with confirmed negative margins longer than 14 days were included. Tumors were excluded if they were metastatic at presentation or received adjuvant therapy. Data were analyzed from October 2023 to August 2024. CSCCs were stratified by the number of the following RFs (0, 1, 2, 3, or 4): a diameter of 2 cm or larger, poorly differentiated histology, tumor extension beyond subcutaneous fat, and large caliber nerve invasion. Five-year cumulative incidences of local recurrence, nodal metastasis, distant metastasis, and disease-specific death. A total of 16 844 CSCCs were included (5978 female individuals [35.5%]; median [IQR] age, 73.9 [65.7-81.8] years), with 0 (12 657 [75.1%]), 1 (2892 [17.2%]), 2 (1015 [6.0%]), 3 ( 225 [1.3%]) or 4 (55 [0.3%]) RFs. Median (IQ) follow up time was 33.6 (14.5-60.3) months. For local recurrence, the risk increased as the number of RF increased from 0 (1.7%; 95% CI, 1.5%-2.0%) to 1 (5.0%; 95% CI, 4.1%-5.9%) to 2 (8.8%; 95% CI, 7.0%-11.0%) to 3 (16.0%; 95% CI, 11.0%-22.0%) to 4 (33.0%; 95% CI, 19.0%-47.0%; P < .001 for between-group differences). This increase was also observed for nodal metastasis (0.6% [95% CI, 0.4%-0.7%] vs 3.6% [95% CI, 2.9%-4.4%] vs 11.0% [95% CI, 9.2%-13.0%] vs 20.0% [95% CI, 15.0%-26.0%] vs 28.0% [95% CI, 15.0%-42.0%], respectively; P < .001), distant metastasis (0.2% [95% CI, 0.1%-0.3%] vs 1.1% [95% CI, 0.7%-1.6%] vs 2.3% [95% CI, 1.4%-3.4%] vs 7.9% [95% CI, 4.6%-12.0%] vs 8.4% [95% CI, 2.6%-19.0%], respectively; P < .001), and disease-specific death (0.3% [95% CI, 0.2%-0.4%] vs 1.9% [95% CI, 1.4%-2.7%] vs 5.4% [95% CI, 4.0%-7.0%] vs 11.0% [95% CI, 6.7%-16.0%] vs 25% [95% CI, 12%-39%], respectively; P < .001). CSCCs with 3 RFs had higher cumulative incidences of local recurrence (1.6-fold), nodal metastasis (1.9-fold), distant metastasis (4.3-fold), and disease-specific death (1.9-fold) compared with those with 2 RFs. The results of this cohort study suggest that the number of RFs is an indicator of risk, and among BWH T2b tumors, those with 3 RFs represent a higher risk subset.