Abstract Introduction The SYNERG-IE research programme aims to address the unmet needs of patients with Sjögren’s disease (SjD) and Sjögren’s associated with additional autoimmune rheumatic diseases (AIRDs), which are chronic, multisystemic conditions that frequently lead to significant morbidity and health service utilization.[1,2] Despite their clinical complexity, there is limited population-based evidence describing hospitalisation patterns among patients with AIRDs in Ireland. Understanding these trends is essential to inform service planning, identify changing patterns of disease burden, and optimise inpatient management strategies. Aim To examine trends and characteristics of hospitalisations related to autoimmune rheumatic diseases in Ireland by analysing the Hospital In-patient Enquiry (HIPE) database. Methods Data were obtained from the HIPE database and included all inpatient discharges with AIRDs listed as the principal diagnosis between 2015–2019 and 2022–2023. AIRDs were identified using the International Classification of Diseases (ICD)-10 codes and included Rheumatoid Arthritis (RA, M05/M06), Systemic Lupus Erythematosus (SLE, M32), SjD (M35.0), Systemic Sclerosis (SSc, M34), Myositis (including Polymyositis/Dermatomyositis, M33), and Mixed/Undifferentiated Connective Tissue Diseases (MCTD/UCTD, M35.1/M35.8/M35.9). Analyses focused on temporal trends in hospitalisations, and descriptive statistics were used to summarise patient characteristics, length of stay (mean, standard deviation), admission type, discharge status, and clinical specialty. Comorbidities (excluding AIRDs) were identified from additional diagnosis records to assess their frequency and distribution. Results Overall, 3942 inpatient hospitalisations were recorded, with RA (65.6%) being the commonest coded condition, followed by SLE (14.1%), and SSc (8.9%). Trend analyses showed overall number of hospitalisations per year remained relatively stable, with a decreasing trend in RA, more marked declines in SjD, and a slight upward trend in SSc, SLE, and myositis. Compared to RA, patients with other AIRDs had significantly longer hospitals stays (mean 5.4 vs 10.4 days), with the longest mean duration of admissions for myositis at 16 days. Prolonged hospitalisations (>90 days) were more commonly observed in patients with myositis and SjD. Patients with SLE and myositis were significantly more likely to have emergency admissions compared to their counterparts. SjD (24.7%) and SLE (27.7%) patients were significantly less likely to be admitted under a rheumatologist. Nephrology and orthopaedics were common specialties to care for hospitalised SLE (22.1%) and RA (21.9%) patients, respectively. We observed significantly higher rates of neurological admissions in SjD patients in comparison to all other AIRDs (24% vs 1.5%). Conclusion This study used comprehensive, national administrative dataset capturing all hospital discharges in Ireland for AIRDs, providing robust population-level estimates; however, the use of routinely coded data limits clinical detail and may be subject to coding variability. We observed a reduction in RA-related admissions over time potentially due to earlier diagnosis and access to advanced therapies. This was offset by increased rates of admission with SSc, SLE, and myositis, and patients with these AIRDs often required prolonged hospital stay. Access to new therapies for AIRD patients as they become available may improve outcomes. High rates of neurological admission in SjD patients warrant prospective evaluation.

ObjectivesTo examine trends and variation in the use of advice and guidance compared with direct referrals in primary care, and to assess potential inequalities across population groups.DesignPopulation based study.SettingClinical Practice Research Datalink (CPRD) Aurum, an anonymised UK primary care database, 1 January 2015 to 31 December 2023.Participants16 340 696 patients with electronic health record data registered in CPRD; 671 894 (4% of the registered population) had advice and guidance recorded and 9 719 796 (59% of the registered population) had a direct referral recorded.Main outcome measuresAnnual prevalence of advice and guidance, and direct referrals, in each calendar year, grouped by age, sex, social deprivation, locality, and ethnic group. Mapping of clinical codes to determine target specialities for advice and guidance. Proportion of individuals recorded with advice and guidance and a direct referral within ±4 months.Results16 340 696 registered patients were analysed between 2015 and 2023; 671 894 patients (4%) had advice and guidance recorded and 9.7 million (59%) had a direct referral. Use of advice and guidance increased 19-fold from 0.10% to 1.97% of the registered population, doubling between 2019 and 2020 during the covid-19 pandemic. Direct referral rates decreased from 23-25% before the pandemic to 18% in 2020, before recovering to 24% by 2023. Cardiology (21%), dermatology (7%) and ear, nose, and throat (5%) were the most common specialties linked to advice and guidance. Most patients receiving advice and guidance (86%) also had a direct referral within ±4 months. Inequities were evident: use of advice and guidance was higher among older, white, and less deprived patients, whereas minority ethnic and more deprived groups had slower recovery of direct referral rates after the pandemic.ConclusionsThe study showed that the use of advice and guidance has increased substantially since 2015, accelerated by the covid-19 pandemic and maintained after, but has not displaced direct referrals. Direct referral often preceded advice and guidance, raising questions about efficiency and equity. Use of advice and guidance was higher among older, white, and less deprived individuals, whereas minority ethnic and more socially deprived groups were more likely to have direct referrals after advice and guidance, suggesting potential delays in access to specialist care. Policy should prioritise dealing with these inequalities and evaluate whether advice and guidance reduces unnecessary referrals or delays access to specialist care.

The Association for Diagnostics & Laboratory Medicine (ADLM) aims to improve health by providing education to laboratory scientists worldwide. Different regions of the world face unique challenges shaped by their national and regional contexts. However, the needs of clinical laboratories worldwide remain largely understudied. To address this gap, we conducted a comprehensive needs assessment survey among laboratory professionals in the Latin American region. The survey was distributed to over 2708 individuals across Latin American countries and yielded 148 responses. Most respondents were from urban areas (74%) and worked in private hospital laboratories (45%), with microbiology (25%) and chemistry (23%) identified as the most common specialties. Key findings include continuing education as the top challenge, identified by 59% of respondents, with a predominant preference for virtual learning formats (83%), though not exclusively; 50% also identified a preference for in-person learning. Other challenges, such as staff shortages, lack of equipment and funding, were selected by 30% to 36% of respondents, whereas regulatory oversight and quality management were less frequently identified as priorities. To contextualize the survey findings, we conducted interviews with laboratory professionals in the region. Common themes included resource and technology constraints, uneven implementation of quality standards, and the need for collaboration between government and professional organizations to bridge gaps in practice. This assessment highlights the need for targeted educational interventions to address the distinct challenges faced by Latin American laboratories. Addressing these gaps in continued education, fostering collaboration, and engaging stakeholders in the region offer a roadmap to strengthening laboratory services and health outcomes.

Background: Since 2018, the number of left ventricular assist devices (LVAD) implantations in Korea has been steadily increasing. Consequently, an increasing number of LVAD patients are presenting for non-cardiac surgery (NCS) of varying complexity. However, recent data on the perioperative management and clinical course of these patients remain limited. We share our investigation on patient and perioperative risk factors, as well as perioperative adverse outcomes, including mortality, in LVAD patients undergoing NCS. Methods: We retrospectively reviewed medical records of 36 LVAD patients who underwent NCS at our tertiary care center between 2018 and 2024. Patients requiring VA-ECMO were excluded. The primary end point was in-hospital mortality. The secondary end point was a composite of complications, including postoperative pulmonary complications, acute kidney injury, cerebrovascular accident, postoperative bleeding or thrombosis, and hemodynamic instability. Using univariable and multivariable logistic regression analysis, we examined the correlation between perioperative factors and adverse outcomes. Results: A total of 53 NCS index cases across 40 hospitalizations were analyzed. General surgery was the most common specialty (n = 19, 35.8%), followed by thoracic surgery (n = 13, 24.5%), plastic surgery (n = 7, 13.2%), and neurosurgery (n = 4, 7.5%). Thirteen procedures (24.5%) were classified as major surgeries. Postoperative complications occurred in 24 patients (66.7%), and 8 patients (20%) experienced mortality. Multivariable regression analysis identified major surgery (adjusted odds ratio [aOR] 1.44; 95% CI 1.11-1.86; p = 0.010), and intraoperative transfusion of ≥3 units of packed red blood cells (aOR 1.47; 95% CI 1.05-2.04; p = 0.029) as significant predictors of in-hospital mortality. Undergoing NCS within 180 days after LVAD implantation was associated with an increased risk of composite complications (aOR 1.86; 95% CI 1.53-2.27; p < 0.001). Conclusions: LVAD patients undergoing non-cardiac surgery frequently experience postoperative complications. Major surgeries, significant intraoperative transfusions, and early surgery following LVAD implantation are key predictors of poor outcomes. Careful risk assessment and tailored perioperative management are essential in this population.

Burnout syndrome is an occupational condition resulting from chronic work-related stressors and it tends to be higher in medical professionals. This study aims to assess burnout among trainee doctors within a nationally accredited postgraduate medical education (PGME) system and identify self-reported contributing factors. This cross-sectional study utilized data from the annual Trainees Survey conducted by the National Institute for Health Specialties (NIHS), the national accrediting body responsible for postgraduate medical education (PGME). The survey, which included the Oldenburg Burnout Inventory (OLBI) to assess emotional exhaustion and disengagement, was disseminated to all doctors enrolled in accredited training programs between March and October 2023. Out of 1618 residents and interns invited, 653 (40.4%) completed the OLBI. There were 473 females (72.4%), 201 Emirati (30.8%) trainees with 212 interns (37.8%) and 440 residents (61.1%). The most common specialties were Pediatrics (103 trainees; 15.8%), Internal Medicine (71 trainees; 10.9%) and Family Medicine (71 trainees; 10.3%). Using validated OLBI cut-off scores, burnout syndrome was identified (with either emotional exhaustion or disengagement) in 136 trainees (20.8%). On the disengagement scale, 79 trainees (12.1%) reported feeling disengaged at work, indicating a cynicism profile. On the exhaustion scale, 113 trainees (17.3%) reported feeling exhausted from work duties, indicating an overextended profile. Burnout in both dimensions, representing a severe burnout profile, was identified in 56 participants (8.6%). High burnout levels were particularly noted in Internal Medicine, Family Medicine, General Surgery, and among medical interns. Multivariate analysis identified duty hour violations (adjusted OR 1.42) and lower satisfaction with supervision and teaching (adjusted OR 0.31) as significant predictors of burnout. Burnout affects approximately one-fifth of trainee doctors in this nationally accredited system, with duty hour violations and inadequate supervision emerging as modifiable risk factors. These findings support targeted interventions focusing on workload regulation and enhanced faculty engagement to improve trainee well-being.

This study sought to determine the incidence of Neuralgic Amyotrophy (NA) in the United States of America's health system, most common presenting symptoms, time from symptom onset and time from initial presentation to diagnosis, number and specialty of clinicians seen prior to diagnosis, and specialty of diagnosing clinician. A retrospective chart review study was conducted to identify all patients diagnosed with ICD-10 G54.5 from September 1, 2016-December 31, 2023. 153 patients with NA diagnoses from 2016 to 2023 were included. The average incidence of NA in the United States of America's healthcare system was 1.77/100,000 per year. The most common chief concern upon presentation was shoulder pain, (n = 57, 37.2%) and the most common secondary or tertiary concern was shoulder weakness (n = 41, 26.7%). Average time from symptom onset to diagnosis was 101.3 days (SD = 155.4; median = 51 days), and from initial presentation to diagnosis was 78.1 days (SD = 145.6; median = 28 days). Sixty-three patients (41.2%) presented to one other clinician with similar symptoms prior to diagnosis, 37 (24.2%) saw two clinicians, 16 (10.5%) saw three, and 7 (4.6%) saw four or more clinicians. Patients most often initially presented to a family medicine, primary care, or urgent care clinician (n = 61, 39.9%). The most common specialties of diagnosing clinicians were orthopaedic surgery (100 diagnoses, 65.4%), neurology (23 diagnoses, 15%) and neurosurgery (15 diagnoses, 10%). Diagnosis of neuralgic amyotrophy is historically rare, but the incidence may be higher than previously thought. Neuralgic amyotrophy is a debilitating disorder that is often initially unrecognized, ultimately leading to a months-long delay in diagnosis. Over 80% of patients were seen by at least one other clinician before diagnosis, and orthopaedic clinicians were most likely to make the diagnosis. Maintaining a high clinical suspicion while recognizing the common presenting symptoms along with onset and evolution of symptoms would help facilitate timely referral to specialists trained in identifying and managing neuralgic amyotrophy, prevent unnecessary and unproductive appointments preceding the diagnosis, and allow earlier initiation of treatment. Diagnostic Type IV.

Background: Mobile surgical units (MSU) have been used since World War II to facilitate surgical care at the frontlines. However, their role in modern-day surgical practice, particularly in austere environments and low-to-middle-income countries (LMIC), is not clear. This study aimed to perform a systematic review of the current literature and illustrate different types of MSUs and their uses, benefits, and limitations. Methods: A PRISMA-compliant systematic review was conducted using PubMed, OVID Medline, CENTRAL, Embase, Scopus, and Web of Science from inception to April 2023. Studies evaluating MSU use in LMICs or austere environments were included. Two reviewers independently screened titles, abstracts, and full-text articles, with consensus achieved by a third reviewer. Data extraction and level of evidence assessment were performed using the Oxford Centre for Evidence-Based Medicine classification. Results: Of 460 studies identified, 24 were included in the analysis. The most common MSU model was truck/bus-based (n=15, 62.5%), followed by portable models including the "SurgiBoxTM" sterile operative field. General surgery was the most common specialty (n=10, 41.7%), followed by obstetrics and gynecology (n=7, 29.2%). Main benefits included improved patient access, reduced wait times, and lower costs compared to conventional operating rooms. Limitations included crowding with increased surgical site infection risk (up to 14.3% in one study) and sustainability concerns. Study quality was poor, with 58.3% being case series (Level 4 evidence). Conclusions: MSUs represent promising alternatives for providing surgical care in LMICs and austere environments. However, further research and improvement of MSU designs are required to enhance safety and reduce perioperative complications.

Abstract Background Infection represents a significant health burden affecting all patient demographics, and thousands of pathogens are known to cause infections in humans; however, many pathogens may not be identified using traditional diagnostic methods. This limitation arises partly from the challenges of growing organisms in conventional culture media, and when employing PCR, the requirement for sequence-specific amplification complicates matters. To overcome these obstacles, in recent years, plasma cell-free metagenomic next-generation sequencing (NGS) has emerged as a noninvasive method to identify and quantify pathogen DNA in plasma. We aimed to gather insights on the clinical use of NGS from both Infectious Diseases (ID) and Non-ID providers.Table 1:Demographics and Question Responses of Perspectives of Next-generation Sequencing Serologic Tests Among All Participants Page 1Table 1:Demographics and Question Responses of Perspectives of Next-generation Sequencing Serologic Tests Among All Participants Page 2 Methods From October 1-November 30, 2024, we conducted a cross-sectional survey among USA and Canadian providers using a purpose-driven sampling among national ID and internal medicine society membership databases. Questions related to NGS use in specific scenarios (Supplemental Document 1). 6 weekly email reminders were sent.Table 2:Comparison of Clinical Utilization Perspectives and Practices of Next-generation Sequencing Serologic Tests Between Infectious Diseases and Non-Infectious Diseases Providers Page 1Table 2:Comparison of Clinical Utilization Perspectives and Practices of Next-generation Sequencing Serologic Tests Between Infectious Diseases and Non-Infectious Diseases Providers Page 2 Results 55 participants initiated the survey, and 34 reported using NGS and completed the remainder of the survey. There most common specialties represented were adult ID (33%), pediatric hematology-oncology (33%), and pediatric ID (18%). The median age was 39 years (IQR 33-54), and 63.6% were female. 81.8% participants were from academic centers (Table 1). Compared to Non-ID providers, ID specialists were older (Median age 33 v. 44, p &amp;lt; 0.04) more likely to have ordered NGS in the past (85% v. 46%, p-value &amp;lt; 0.01), and less likely to order for infection surveillance/pre-emptive therapy in an at-risk population (0% v. 8.8%, p-value &amp;lt; 0.01; Table 2). Conclusion Our cross-sectional survey revealed notable differences among providers regarding specific applications of NGS in clinical care. Although limited by a low response rate and survey completion percentage, this preliminary data could inform the development of enhanced NGS assessment projects. These insights may illuminate the use of NGS and influence future implementation and cost-effectiveness studies. Disclosures All Authors: No reported disclosures

To determine whether benzodiazepine (BZD) prescriptions in older adults (>65) generally adhere to the Beers Criteria of the American Geriatrics Society, and whether the likelihood of prescribing an average of > 30 days per beneficiary to older adults varies significantly, Medicare Part D prescribing patterns were analyzed based on prescriber location and specialty. The 2017-2023 Medicare Part D Prescriber Public Use and Summary files were evaluated, with drug event information aggregated by provider and type of drug. The most prescribed BZD and the most common prescriber specialty for each year was determined, as well as the drug utilization rate by state. Medicare Part D BZD prescriptions rose from 1.7 million to 3.1 million, an increase of over 80%, between 2017 and 2023, while overall U.S. BZD prescriptions decreased by about one-quarter during this same period, from 110 million to 81 million. The top three most prescribed BZD medications were alprazolam, lorazepam, and clonazepam, totaling around 88% of all the BZD prescriptions being written to Part D beneficiaries. When adjusted for the number of prescribers, all classes of prescribers increased their use of BZDs. Psychiatry was the top prescribing specialty, and showed the most increase in BZD prescription rate. The southeast region of the U.S. had the highest BZD utilization rates, with approximately 25 prescriptions dispensed for every 100 beneficiaries. In 2023, psychiatrists were more likely to prescribe BZDs for >30 days compared to nurse practitioners, physician assistants, and providers in the 'other' category, but less likely than family practice, internal medicine, and geriatric medicine providers. Compared to California, significantly increased odds of prescribing >30 days were found in 13 U.S. states; significantly decreased odds occurred in 5 states. Despite guidelines recommending against prescribing BZDs to adults ≥ 65 years and limiting prescriptions to 30 days or fewer, all years studied exceeded these guidelines, averaging 108 days of BZD per beneficiary. Despite repeated warnings about the harms of their use in this population, BZDs are being increasingly prescribed to Medicare Part D recipients. Some states and prescriber classes prescribe BZDs significantly over 30 days per beneficiary to older adults.

We aimed to quantify the financial impact of a single red blood cell (RBC) unit transfusion. We included all adult patients who underwent elective non-cardiac surgery from 2014 to 2021 and received either none or a single RBC transfusion. Clinical and economic data were retrieved from electronic records and billing systems using a bottom-up, micro-costing approach, including 80,944 surgical admissions. Mean age was 60.6 ± 18.1 years, 40,541 (50.1%) were female, and 27,661 (34.2%) were classified ASA score ≥ 3. In total, 2,727 (3.4%) patients received an RBC transfusion. The average length of stay was 6.3 ± 9.2 days. The most common surgical specialty was orthopedics, followed by general surgery. Unadjusted analyses revealed higher costs in the transfused group. After adjusting for age, sex, ASA score, preoperative hemoglobin value, length of stay and hospital site, the hospital costs were USD 11,724 (IQR 3,481 − 21,872) compared to USD 11,233 (IQR 6,736 − 19,336) in the non-transfused group (p = 0.018). RBC transfusions represent a significant economic burden in adult elective non-cardiac surgical patients. Regardless of its appropriateness, each transfusion increased hospital costs by an average of USD 491 compared to non-transfused patients, corresponding to 5.2% of the median total hospital cost. Patient blood management policies should be implemented in hospital trusts to minimize transfusion rates in elective surgery.

Catheter-related bloodstream infections (CRBSIs) are associated with longer hospital stays and increased mortality risks. The Replacement at Standard vs Prolonged Interval (RSVP) trial found that central venous access devices and peripheral arterial catheter infusion set replacement intervals can be extended from 4 to 7 days without increasing infection risk by more than 2%. However, the trial did not consider the full cost and health trade-offs of extending replacement intervals. To estimate the changes in total cost and health benefits associated with a decision to adopt 7-day vs standard 4-day replacement intervals via decision-analytic modeling. In this economic evaluation, a decision tree model was developed on August 26, 2025, from a health care perspective incorporating data from patients in the RSVP randomized clinical trial conducted from 2011 to 2016 across 10 Australian hospitals. Data were analyzed from December 12, 2016, to April 23, 2019. A probabilistic sensitivity analysis generated a joint distribution of the expected change to cost and effectiveness outcomes. Parameter uncertainty was assessed, a cost effectiveness acceptability curve was plotted, and a value of information analysis was done. Of 2941 patients from the RSVP trial (median age, 59.0 years; range, 47-68 years), 62.9% were male. Of patients, 62.6% were admitted to intensive care, and common specialties were medical, hematology, and emergency surgical. A CRBSI risk of 1.78% in the 7-day group and 1.46% in the standard 4-day group was reported. The 7-day strategy was associated with annual savings of approximately 52 million Australian dollars (A$) (95% uncertainty interval [UI], -A$42 841 427 to A$181 823 300) from fewer set changes, offset by A$3.1 million (95% UI, -A$6 974 903 to A$14 099 754) in additional costs for treating CRBSI. The expected health outcomes were 395 (95% UI, -945 to 1739) additional infections, 103 (95% UI, -246 to 452) excess deaths, and 1724 (95% UI, -4199 to 7925) life-years lost at the population level. At a willingness-to-pay threshold of A$28 033, the probability that the 7-day strategy is cost-effective was 50.3%, and the probability that it is cost-saving was 82.67%. In this economic evaluation of the RSVP trial, a small increase in CRBSI risk was associated with large cost-savings and substantial health losses at the population level. While the RSVP trial assumed that a 2% equivalence margin was acceptable, the use of such arbitrary difference margins might not consider information that could change decision-making outcomes. The clinical and economic impacts of small increases to infections appear to be important for decision-making inference.

This study examines the transformation of traditional midwives (авсан ээж) into professional midwives (эх баригч) in 20th-century Mongolia and analyzes how state-led maternal and child health policies evolved during this transition. In traditional Mongolian society, midwives served not merely as birth attendants but as ritual specialists who presided over placenta burial ceremonies, sacred bathing rituals, and naming ceremonies. Interestingly, both female and male midwives existed, reflecting the nomadic lifestyle where livestock birthing experience and geographical constraints necessitated flexible gender roles. Following the 1922 introduction of the Soviet Semashko medical model, Mongolia’s maternal health care was fundamentally restructured. The first obstetrics ward was established in 1928, and the 1950s-1960s witnessed comprehensive expansion of medical infrastructure, including “maternity waiting homes” (эх барих газар) for rural women. Infant mortality declined from 109 per 1,000 live births in 1960 to 57.4 in 1990, while maternal mortality decreased by approximately 25%. Women came to comprise 71.3% of all physicians by 1990, with obstetrics ranking as the third most common specialty. However, the 1990 collapse of socialism precipitated a severe crisis. The suspension of midwifery education from 1993 to 2003 created a generational knowledge gap, and some rural areas experienced maternal mortality rates 4-5 times higher than urban areas. Contemporary Mongolia exhibits a dualistic system: urban midwives assist obstetricians within a biomedical model, while rural midwives maintain autonomous practice managing prenatal care and normal deliveries independently—reminiscent of traditional comprehensive care functions. This study demonstrates that medical modernization involves complex negotiations between tradition and modernity. While the transition achieved significant mortality reductions, it also resulted in the loss of ritual and spiritual dimensions of childbirth care. The persistence of autonomous rural midwifery suggests that comprehensive, community-based care models retain value within modern medical systems.

Medical residents are among the most vulnerable healthcare workers making their job satisfaction a critical factor influencing mental health, quality of care, and retention. This study examines how resilience and perfectionism are associated with job satisfaction among Croatian medical residents, with particular attention to perfectionism's mediating role in these relationships. In a cross-sectional study, 148 residents (79.1% female; median age 30 years, IQR 29-32) completed an online survey between April and May 2024. Snowball sampling was conducted via closed social media groups for residents. Instruments included validated Croatian versions of the Brief Resilience Scale, the Multidimensional Perfectionism Scale, and the Index of Job Satisfaction. Participants were most frequently in their third year of training (Md = 3, IQR = 2-4); the most common specialty was anesthesiology (n = 17). Concern about mistakes, a maladaptive dimension of perfectionism, was negatively correlated with resilience (r = -0.476, p < 0.001) and job satisfaction (r = -0.375, p < 0.001). Regression analysis identified concern about mistakes as the sole predictor of job satisfaction (adjusted R2 = 0.112). Mediation analysis showed that concern about mistakes partially mediated the relationship between resilience and job satisfaction. Other perfectionism dimensions were not significant predictors. This study found that concern about mistakes, a maladaptive form of perfectionism, mediated the relationship between resilience and job satisfaction among Croatian medical residents. Other perfectionism dimensions were not significant predictors. These findings highlight maladaptive perfectionism as a key factor influencing resident resilience and job satisfaction.

Epinephrine is frequently used in combination with local anesthetic agents to enhance their efficacy and duration of action. However, its use in anatomical regions supplied by end arteries remains a topic of controversy. The primary aim of this study was to evaluate physicians’ knowledge and practices regarding the use of epinephrine in combination with local anesthetics in end-arterial regions. We also aimed to estimate the prevalence of its use among Jordanian physicians and to examine variations in practice according to physician seniority and medical specialty. A cross-sectional study was conducted using a web-based questionnaire targeting Jordanian physicians. The questionnaire consisted of 3 sections that evaluated participants’ demographics, knowledge regarding epinephrine use with local anesthetics in end anatomical arteries, and practices related to general and local anesthesia when performing procedures on these areas. Data were analyzed using Jamovi 2.4.14 software. Of the 336 physicians, 56.5% were males, and 74.4% were aged 35 or younger. General surgery was the most common specialty (61.5%), with 74.7% of participants having <5 years of experience. Residents formed the majority (68.1%), while specialists comprised 31.9%. The overall knowledge about the safety of epinephrine with local anesthesia was low with scores of 3.53 ± 2.20, 2.11 ± 1.95, and 1.57 ± 2.20 for fingers/toes, nose/ears, and penile subgroups, respectively. Our results showed no statistical difference between junior and senior physicians in their choice between general and local anesthesia when operating on the penis (P-values = .564 and .571 for general anesthesia and local anesthesia, respectively). Also, hesitancy in using epinephrine was evident among fingers/toes and penile surgeons, being more obvious in the latter. Despite growing evidence supporting the safety of epinephrine in end-arterial regions, hesitancy remains obvious among Jordanian physicians, particularly in penile surgeries. Limited knowledge and variable practices across specialties highlight the need for targeted education and updated guidelines to fill the gap between evidence-based recommendations and clinical practices.

Neuropathic corneal pain (NCP) is a challenging condition with limited consensus on its diagnosis and management. This study aimed to gather global insights from corneal specialists on the causes, investigative approaches, and management strategies for NCP. A 32-question survey covering demographic, causes, investigations, treatments, and multidisciplinary engagement was sent to 152 invited international corneal specialists; 51 (34%) responded. We explored descriptive statistics and examined how responder characteristics influenced their answers. The most reported causes of NCP were chronic ocular surface disease (n = 41; 41%) and post-surgical factors (n = 34; 34%). The most common investigations, routinely performed by respondents, were the anesthetic challenge test, Schirmer's test, and corneal esthesiometry. In vivo confocal microscopy (IVCM) was routinely used by 37% (n = 19), with 69% (n = 29) of specialists stating that an abnormal result influenced their management. Ocular surface and pain questionnaires were used by 69% (n = 35), with the Ocular Surface Disease Index being the most popular (n = 25; 31%). Common treatments included artificial tears (n = 48; 94%), serum/plasma-derived tears (n = 41; 80%), topical corticosteroids (n = 34; 67%), and topical cyclosporin (n = 30; 59%). Only 38% (n = 19) felt comfortable independently prescribing systemic pharmacotherapy. A multidisciplinary approach was adopted by 47% (n = 24), with the two most common specialties involved being pain management (n = 30; 37%) and neurology (n = 26, 32%). This survey provides valuable global insights into the causes, investigations, and management of NCP from the perspective of corneal specialists. These findings support further research and the development of guidelines to address this challenging condition.

Chronic wounds affect approximately 10.5 million individuals annually in the United States. Although recent studies have highlighted a surge in chronic wound cases among younger populations, the collective burden of pediatric chronic wounds remains understudied. This study aims to elucidate the epidemiology and management of pediatric chronic wounds. A comprehensive literature search was conducted across Embase, PubMed, and Web of Science databases on articles published after 2000 that specified chronicity of wounds in pediatric patients. The exclusion criteria included case reports, review articles, and proceedings. Sixteen articles met the inclusion criteria. Pilonidal sinus disease emerged as the most studied chronic wound etiology (38%), followed by dermatological disorders such as epidermolysis bullosa, pyoderma gangrenosum, and cutaneous nontuberculous mycobacterium (25%). Traumatic wounds were covered in three articles (19%), whereas burns, pressure ulcers, and osteomyelitis each represented 13% of the studies. This review revealed an interdisciplinary framework, with pediatric surgery being the most common specialty, alongside dermatology and allied health professionals. Most studies examined epidemiology, assessing demographics, nutrition status, and comorbidities, including diabetes mellitus, obesity, hidradenitis suppurativa, and myelomeningocele. Management strategies frequently discussed surgical procedures and wound dressings, whereas self-management and educational initiatives were described to enhance patient care. This systematic review synthesizes current evidence on epidemiology and management approaches for pediatric chronic wounds. Addressing this public health concern requires equitable allocation of resources toward research focused on prevention and enhanced treatment strategies.

Informed consent (IC) practices for endovascular thrombectomy (EVT) in acute stroke are not well elucidated. We investigated the roles and specialties of those obtaining EVT IC, aiming to provide insights for enhancing the process. We conducted a survey from July- December 2023 among acute stroke care clinicians. Utilizing Qualtrics, we disseminated a questionnaire through various national and international online platforms. This analysis summarizes the characteristics of individuals who obtain IC at respondents' institution. Among 168 respondents, 71% were staff physicians, 70% practiced in the US and 70% worked at academic centers. Neurology (77%) was the most common specialty obtaining EVT IC, followed by neurosurgery (41%), radiology (30%) and emergency medicine (EM) (10%). Staff physicians were the most frequently involved (61%), followed by fellows (43%), residents (48%) and advanced practice providers (APPs) (36%). Comparatvely, non-US institutions were more likely to utilize neurologists alone (50% vs 31%, P = 0.016) and staff physicians (76% vs 54%, P = 0.008), while US institutions more often utilized neurosurgeons (51% vs 18%, P < 0.001), APPs (43% vs 18%, P = 0.002) and residents (56% vs 28%, P = 0.001). Non-academic institutions used EM (25% vs 5%, P < 0.001) and APPs (50% vs 31%, P = 0.031), while academic institutions commonly utilized neurosurgeons (48% vs 18%, P = 0.001), residents (59% vs 13%, P < 0.001) and fellows (52% vs 18%, P < 0.001). Neurologists and staff physicians are the primary providers obtaining EVT IC, with variations based on region and institution type. Future efforts to optimize the IC process should integrate various specialties and be widely adaptable.

SNAP-3: characteristics of specific subgroups of older patients undergoing surgery in the UK

Abstract AIMS Awake craniotomies (ACs) are increasingly seen as the gold standard for resecting tumours in eloquent regions of the brain. However, insights collected through the TJ (Tessa Jowell) Academy suggest that there is variation in how ACs are delivered in the UK, potentially impacting which patients have an AC and who supports these surgeries. To explore this variation we conducted a thorough review of AC delivery in 22 UK neuro-oncology centres as part of the TJ CoE (Centre of Excellence) programme. METHODS UK neuro-oncology centres applying for TJ CoE in 2024 detailed the number of ACs delivered each year, and were asked to describe which allied health professional (AHP) specialties supported these procedures. Data were grouped by theme and analysed, and are presented here anonymously. RESULTS While all 22 centres applying for TJ CoE in 2024 conducted awake craniotomies, the percentage of surgeries done awake varied from 3% to 39%. The split between high- and low-grade patients varied, with three centres only operating awake on low-grade tumours. The number of distinct AHP specialties supporting ACs (dependent on the patients’ needs/tumour location) var- ied from 1 to 6: the most common specialties were speech and language therapist (SLT) and neuropsychologist (both 16/22, 73%) followed by physiotherapist (10/22, 45%) and neurophysiologist (9/22, 41%). Only a minority of centres reported that all their AHPs had time funded for the AC pathway (36%, 8/22), and 7/22 centres reported no AC-specific training for AHPs. CONCLUSION These findings suggest that the existing lack of guidelines on AC delivery has led to variation in which patients are operated on, and which AHPs support these surgeries. These data will inform the upcoming publication of national guidance on ACs by the TJ Academy’s physiotherapy, SLT and neuropsychology task-and-finish groups, with the aim to encourage a more standardised approach to AC delivery across the UK.

This study aimed todescribe the characteristics of American Board of Obesity Medicine (ABOM) physician diplomates over the last 8 years (2017-2024). Using the ABOM database, we conducted a cross-sectional study of physicians who achieved initial ABOM certification between 2017 and 2024. Characteristics included demographics, primary medical specialty, years of obesity medicine experience, patient population, and practice setting. We conducted descriptive analyses and compared current characteristics with estimates extracted from the published ABOM 5-year report (2012-2016). Overall, 8640 physicians achieved initial ABOM certification between 2017 and 2024; 2068 achieved certification between 2012 and 2016. Between the 2012-2016 and 2017-2024 groups, notable differences were increases in physicians under age 40 years (22.7% vs. 47.6%, respectively), women (52.8% vs. 64.0%, respectively), and practicing obesity medicine for less than 2 years at initial certification (40.2% vs. 68.3%, respectively). The most common primary medical specialties were internal medicine (32.4%), family medicine (29.2%), and internal medicine subspecialties (14.2%). We found that recent ABOM diplomates are likely entering the field earlier in their careers and with fewer years of obesity medicine experience than the initial group. Future investigation is needed to understand how ABOM and other obesity organizations can best support these physicians in their transition to obesity medicine clinical practice.