St Michael's Hospital

Hip arthroscopy is an increasingly common outpatient surgical procedure where postoperative pain can be severe. Peripheral nerve blocks have been evaluated for analgesia following hip arthroscopy; however, there is no consensus on an optimal technique that provides effective local anesthetic-based postoperative analgesia without motor blockade. We hypothesized that the pericapsular nerve group (PENG) block would provide effective motor-sparing analgesia following ambulatory hip arthroscopy. We conducted a randomized placebo-controlled double-blind trial comparing an ultrasound-guided PENG block with 20 mL of 0.5% ropivacaine to a control with a sham injection. Our primary outcomes were cumulative opioid consumption (oral morphine equivalent) and quality of recovery (QoR-15) scores at 24 hours postoperatively. Secondary outcomes included pain, postoperative opioid consumption, time to first analgesic request, postanesthesia care unit (PACU) length of stay, and opioid and block-related side effects. 94 patients were included (47 per group). QoR was similar between groups at 24 hours as measured by the QoR-15 (range 0-150, higher scores indicate better recovery): mean SD 96.8±20.9 in the PENG group versus 101.0±20.9 in the control group (mean difference -4.2; adjusted p=0.414). Opioid consumption at 24 hours was also similar between groups. In adjusted analyses, the PENG group required less opioid analgesia in the PACU (mean difference -9.5 MME; p=0.039) and had a shorter PACU stay (mean difference -20.5 min; p=0.027). Pain scores at rest and on movement decreased over time in both groups, with no consistent differences in overall pain trajectories. Opioid consumption at 48 hours, opioid-related adverse effects and block-related complications were similar between groups. When administered preoperatively, the PENG block provides only modest early perioperative benefits without improving overall postoperative analgesia or QoR in patients undergoing ambulatory hip arthroscopy. Based on these findings, routine preoperative use of the PENG block for ambulatory hip arthroscopy cannot be recommended beyond standard multimodal analgesia, although it may be considered selectively to facilitate early PACU recovery in carefully chosen patients. The potential role of postoperative PENG block as a rescue intervention warrants further investigation. NCT03449680; https://clinicaltrials.gov/study/NCT03449680.

The Cenozoic Era provides a key framework for investigating how ocean oxygenation and marine productivity responded to past global warming events, offering valuable analogues for ongoing and future climate change. Here, we integrate foraminifera-bound nitrogen isotopes (FB-δ¹⁵N) with stable carbon and oxygen isotopes (δ¹³C, δ¹⁸O) to reconstruct nitrogen-cycle dynamics, water-column oxygenation, and photosymbiotic behaviour in planktic foraminifera across the Middle Eocene Climatic Optimum (MECO; ~40 Ma), a major greenhouse interval lasting ~500–600 kyr. The dataset is based on planktic foraminifera from two Atlantic sites spanning contrasting latitudes: subtropical ODP Site 1051 and subantarctic ODP Site 702. FB-δ¹⁵N records from both sites show a marked and coherent decrease during the MECO, reaching minimum values at peak warming. This trend indicates a general reduction in water-column denitrification, a process that generally occurs under extremely low oxygen conditions, suggesting that prolonged warming was not associated with widespread deoxygenation in the global ocean . These results are consistent with patterns observed during other Cenozoic hyperthermals (e.g. PETM, EECO, MCO) and imply that enhanced deep-water ventilation and/or reduced biological productivity counteracted warming-driven oxygen loss. Paired δ¹³C and δ¹⁸O data confirm persistent vertical habitat partitioning among planktic foraminiferal taxa, despite partial convergence in δ¹⁸O values during the MECO, indicating upper-ocean thermal homogenization and temporary niche compression. This preservation of depth-related ecological structure supports the interpretation of interspecific FB-δ¹⁵N offsets as reflecting distinct symbiotic strategies. Lower δ¹⁵N values in Acarinina and Globigerinatheka relative to Subbotina confirm their photosymbiotic nature, while systematic differences between the two symbiotic genera suggest dinoflagellate symbionts in Acarinina and non-dinoflagellate algae (e.g. diatoms or coccolithophorids) in Globigerinatheka. The contrasting evolutionary trajectories of these taxa, recording a decline for Acarinina and expansion for Globigerinatheka during and after the MECO, likely reflect differences in symbiont flexibility and sensitivity to photic-zone environmental change. Overall, this study provides the first reconstruction of the nitrogen cycle across the MECO and demonstrates the value of FB-δ¹⁵N, combined with δ¹³C–δ¹⁸O constraints, as a dual proxy for local and global denitrification and planktic foraminiferal ecology during sustained greenhouse warming.

S. 50-56) viel Interessantes und im Zaber gu anscheinend Vergessenes.So hat Holder keine Probleme damit, die Magenheimer als dominante Familie fr das ganze Zabergu -auch fr Bnnigheim -zu sehen; und den "Mond-Geschichten" ist er auch schon auf die Schliche gekommen.Ohne den Namen Klunzinger zu erwhnen, aber mit einiger Sffisanz, schreibt er (S. 45): "Damit wre der Versuch hinfllig, aus Magenheim ein Mohn-oder gar Mondheim herauszuklgeln; man las nm lich statt Magen willkrlich Mohn, sprach dieses probeweise mundartlich Mo(hn) aus, hrte geflissentlich Mo(nd), bersetzte dies nachtrglich pfiffig in die lateinische Sprache und entdeckte dann glcklich eine gewesene Mondsburg, das gesuchte "castrum lunae" der Rmer.Auf diesem Wege gelangte ein kluges Gesicht auch zur Erkenntnis des magenheimischen Wap pens, zwei roten

Abstract Background Accurate loco-regional staging is essential in the management of gastric cancer, guiding decisions regarding neoadjuvant therapy, surgical and endoscopic interventions. Endoscopic ultrasound (EUS) is widely used for evaluating tumor depth (T stage) and regional lymph node involvement (N stage), but reported diagnostic performance varies across studies. Aims This systematic review and meta-analysis aimed to synthesize evidence on the accuracy of EUS for staging gastric cancer. Methods A comprehensive literature search was performed in MEDLINE, Embase and Cochrane Library until May 27, 2025 to identify studies reporting the diagnostic performance of EUS for gastric cancer staging compared with histopathology as the reference standard. Pooled sensitivity, specificity, and accuracy for T and N staging were calculated using a bivariate random-effects model. Heterogeneity was assessed with the I2 statistic, and publication bias was evaluated using Deeks’ funnel plot asymmetry test. Results Across 33 studies including 4,444 patients, conventional EUS demonstrated high diagnostic performance for T staging of gastric cancer. Accuracy was high, ranging from 80% (95% 0.75–0.83) for T3 lesions to 90% (95% CI 0.87–0.93) for T1 lesions. Heterogeneity was substantial (I2 = 82.0–93.7%), reflecting variability in study design, patient populations, and operator expertise. Overstaging and understaging occurred in 14% (95% CI: 0.09–0.20) and 11% (95% CI: 0.09–0.13) of lesions, respectively. Pooled sensitivity ranged from 58% (0.46–0.70) for T4 lesions to 76% (95% CI 0.64–0.87) for T1 lesions. Pooled specificity ranged from 82% (95% CI 0.77–0.86) for T3 lesions to 95% (95% CI 0.93–0.97) for T1 lesions. Area under the curve (AUC) ranged from 0.838 for T4 lesions to 0.924 for T1 lesions. For nodal staging, data from 22 studies encompassing 2,036 patients demonstrated more modest performance. Pooled sensitivity was 67% (95% CI: 0.59–0.75) and specificity was 79% (95% CI: 0.74–0.85), with an overall N staging accuracy of 72% (95% CI: 0.67–0.77), and AUC of 0.797. Heterogeneity was substantial (I2 = 68.6–97.3%), but no publication bias was suggested. Conclusions EUS provides robust diagnostic performance for T staging in gastric cancer, accurately assessing tumor invasion depth and reliably distinguishing early from advanced disease. However, moderate rates of overstaging and understaging persist, and nodal staging performance remains suboptimal. These findings underscore the importance of operator experience, standardized staging protocols, and the potential value of adjunctive techniques, such as EUS-guided fine-needle aspiration or contrast-enhanced EUS to enhance diagnostic yield. Funding Agencies None

Artificial intelligence (AI) and machine learning (ML) are increasingly integrated into healthcare, offering potential advancements in patient-reported outcome measures (PROMs) for surgical populations. Improved PROMs can enhance patient-centered care by accurately capturing patient experiences with minimal burden. In the context of surgery, where recovery trajectories vary widely, this study aims to systematically review the use of AI and ML in the development, application, and prediction capabilities of PROMs in surgical populations, with a focus on psychometric properties and the predictive accuracy of post-surgical outcomes. A comprehensive search of the PubMed database was conducted from inception until August 2024. Studies were included if they utilized AI or ML in the development, application, or predicting PROMs for surgical patients. Methodological quality was assessed using COSMIN and PROBAST tools, depending on study design. A qualitative synthesis of findings was performed. Twenty-two studies met the inclusion criteria, with 19 rated as high quality. Six studies focused on developing computer adaptive tests (CAT) PROMs, seven on evaluating psychometric properties, and five on ML for post-surgical outcome prediction. CAT PROMs showed comparable measurement accuracy to traditional PROMs, good to excellent construct validity, and significantly reduced patient burden by reducing the length of questionnaires. ML algorithms, such as logistic regression, random forests, extreme gradient boosting, and neural networks, achieved similar predictive accuracy for post-surgical outcomes, with no single model demonstrating consistent superiority. AI and ML have the potential to improve PROM utilization in surgical care by enhancing efficiency and personalization while maintaining data quality. Clinicians can use AI-driven PROMs to reduce patient burden and integrate ML models for accurate post-surgical outcome prediction, thereby optimizing patient-centered care.

Traumatic brain injury (TBI) represents a significant health concern, with an estimated 70 million annual cases worldwide. Mild brain trauma (concussions) is the most common TBI (81%), followed by moderate (11%) and severe (8%). Cytokine release and neuroinflammation after TBI may cause blood–brain barrier and tissue damage, triggering unfavorable outcomes, including disabilities and mortality. Current TBI treatments, focused on preventing secondary injury, are limited and insufficient. Therefore, new therapeutic approaches are necessary. A growing body of recent literature supports the potential use of incretins: glucagon-like peptide-1, glucose-dependent insulinotropic peptide, and glucagon receptor agonists, as potent neurotrophic/neuroprotective agents. Experiments performed in cellular and animal models, and a limited number of clinical studies, provide evidence that incretins might be a novel and effective treatment for TBI. Incretin-based compounds have already been shown to be safe and efficacious for the treatment of type 2 diabetes mellitus in humans. Therefore, incretins are ideal candidates for rapid evaluation in clinical trials of TBI and might become a novel therapeutic tool for a condition that has very few disease modifying treatments available. Well-designed human clinical trials are urgently needed to determine optimal dosing, timing, and patient selection for effective incretin use in concussion and TBI.

Child and Adolescent Mental Health Services (CAMHS) face mounting pressures due to increased demand, emotional complexity, and systemic strain. Improving outcomes for young people must go hand-in-hand with supporting the workforce that delivers care. This study describes a service innovation project that applied the COM-B model (Capability, Opportunity, Motivation – Behaviour) alongside behavioural systems mapping to identify barriers and enablers to change in a multidisciplinary CAMHS setting. Through the development of a systems map and structured focus group analysis, staff highlighted key feedback loops contributing to burnout, disengagement, and limited organisational responsiveness. COM-B provided a structured lens to interpret these dynamics and co-produce feasible, context-specific service improvements. This method, adapted from research culture transformation work, offers a novel and transferable approach for service development in mental health settings.

The Low-profile visualized Intraluminal Support EVO (LVIS EVO) is a next-generation braided stent characterized by enhanced visibility and resheathability, and designed for stent-assisted coil embolization of intracranial aneurysms. Despite growing adoption, real-world data on its efficacy and safety remain limited. This study aims to evaluate the safety and efficacy of the LVIS EVO stent in consecutive patients undergoing treatment for brain aneurysms. We retrospectively analyzed all patients who underwent treatment of unruptured intracranial aneurysms with the LVIS EVO stent in a single tertiary center between January 2021 and January 2024. Baseline demographics, imaging and procedural characteristics, clinical outcomes, and clinical and radiological follow-up data were collected. The primary endpoints were successful deployment and complete aneurysm occlusion at follow-up as defined by the Raymond-Roy Occlusion Classification. Secondary endpoints included complication rate, modified Rankin Scale (mRS) at last clinical follow-up, and incidence of in-stent stenosis on last follow-up imaging. Thirty-four patients (64.7% women; median age: 52 years) were treated for 34 saccular aneurysms. Most of the aneurysms were previously ruptured and recanalized after initial treatment (20/34, 58.8%). They were mainly located at the middle cerebral artery (15/34, 44.1%) and the internal carotid artery terminus (8/34, 23.5%), with additional cases at the anterior communicating artery (7/34, 20.6%) and the posterior circulation (4/34, 11.8%). Median aneurysm neck size was 3.3mm, with an aspect ratio of 1.2 and a dome-to-neck ratio of 1.3. Stent deployment was successful in 100% of cases. Immediate complete occlusion (RROCs I) was achieved in 82.4% of aneurysms. At a median radiological follow-up of 24 months, 91.2% of aneurysms remained completely occluded, and 97.1% were adequately occluded (RROC I-II). Two intraprocedural cases (5.9%) of in-stent thrombosis occurred and were managed successfully. One post-procedural symptomatic ischemic event occurred, but the patient was asymptomatic at the last clinical follow-up. There were no hemorrhagic or permanent ischemic complications. Asymptomatic in-stent stenosis occurred in 2 patients (5.9%). Clinical outcome was favorable (mRS ≤ 2) in 100% of cases at last follow-up. The LVIS EVO stent demonstrates excellent technical success and sustained aneurysm occlusion with a low complication rate. These results support its safety and efficacy in the treatment of intracranial aneurysms, including previously ruptured lesions and anatomically complex locations.