Core Elements of Goals of Care Initiatives Across Eight Health Systems.

Effectiveness of exercise interventions for adolescent idiopathic scoliosis: An umbrella review.

The MetALD-ALD Prediction Index: A Phosphatidylethanol-Driven Biomarker Panel for Identifying Individuals With Steatotic Liver Disease and Excessive Alcohol Use.

To evaluate real-world clinical use of semaglutide in obese patients, focusing on titration, tolerability and short-term efficacy. This retrospective study included obese patients treated with the weekly injectable semaglutide. Data on body weight, waist circumference, lipid profile, doses, reasons for maintenance, adverse events, and discontinuations were collected at 3 and 6 months. A total of 111 patients were included (80% women; mean age 51.12; median body mass index (BMI) 35.56 kg/m2; median body weight 97.00 kg). About 81.1% of patients initiated therapy at 0.25 mg, while 72.1% increased to 1 mg after 3 months. By 6 months, 2% remained on 0.5 mg, 40% on 1 mg, and 26% on 2.4 mg. The main reasons for maintaining the dose were satisfaction with the outcomes, followed by cost and adverse events. Significant reductions in weight, BMI, waist circumference and waist-to-height ratio were observed at both time points, with greater improvements seen in patients with a baseline BMI of ≥35. Weight loss of ≥5%, ≥10%, ≥15% and ≥20% was achieved by 23.5%, 34.6%, 30.8% and 11.1% of patients, respectively. There were no differences by sex, previous treatment or final dose. Adverse events occurred in 56.8% of patients at 3 months, leading to discontinuation in three patients. This percentage halved by 6 months (a 32.6% rate), with two cases leading to discontinuation. The rate of early discontinuation was 6.3% at 3 months, rising to 10.5% at 6 months due to cost, adverse events, or inefficacy. This real-world analysis provides valuable insights into the use of semaglutide in routine clinical practice, confirming a favourable efficacy profile with flexible dosing patterns.

Lecanemab is a monoclonal antibody targeting amyloid-beta protofibrils, indicated for patients with mild cognitive impairment (MCI) and mild dementia due to Alzheimer's disease. This study reports interim findings of an ongoing, multicenter, prospective, observational post-marketing study for all patients treated with lecanemab in routine clinical practice in Japan, focusing on amyloid-related imaging abnormalities (ARIAs) and infusion-related reactions primarily observed during up to 28 weeks after treatment initiation. Patients treated with lecanemab at any medical institutions across Japan are included in the study. Data are collected using an electronic data capture system via standardized case report forms (CRFs). Study items included the incidence of ARIA, ARIA-edema or effusion (-E), ARIA-hemorrhage (-H: cerebral microhemorrhages, superficial siderosis, and macrohemorrhage), and infusion-related reactions, reported as adverse drug reactions. As of July 5, 2025, CRFs from 2675 patients were collected, of whom 2672 had data available for the interim analysis. The median age was 76.0 years, and 62.6 % (1672/2672) of patients were diagnosed with MCI. At Week 28, 7.3 % (195/2672) of patients discontinued treatment, with a mean treatment duration of 189.6 ± 34.4 days. Among 2634 patients confirmed to have undergone MRI scans after treatment initiation, ARIA was observed in 7.1 % (188/2634) of patients, ARIA-E in 3.0 % (78/2634), and ARIA-H in 5.2 % (137/2634). Serious ARIA-H (macrohemorrhage) occurred in two patients (0.1 %). Infusion-related reactions were observed in 17.0 % (455/2672), including 0.7 % (18/2672) serious cases. The proportion of patients who experienced ARIA was highest in patients with apolipoprotein E (APOE) ε4 homozygotes. This interim analysis represents one of the largest real-world lecanemab cohorts reported globally to date. Although absolute rates are not directly comparable with those from clinical trials, the trends in ARIA distributions across APOE genotypes and infusion-related reactions were comparable to those observed in clinical trials.

A laboratory-driven clinical decision support system algorithm for personalized and automated cardiovascular risk stratification in primary care patients.

Impact of vial geometry on 18F radionuclide calibrator response using 68Ge/68Ga surrogate sources.

Low-dose ruxolitinib as first-line therapy for acute graft-versus-host disease (aGVHD) increases the risk of Epstein-Barr virus (EBV) reactivation but not posttransplant lymphoproliferative disease (PTLD).

Proton pump inhibitor deprescribing interventions in primary care: A systematic review

To compare 3-month clinical outcomes of patients treated with ultrasound-guided carpal tunnel release (UGCTR) or endoscopic carpal tunnel release (ECTR) in routine clinical practice. This prospective multicenter observational study enrolled patients with carpal tunnel syndrome who were treated with UGCTR or ECTR by experienced surgeons. Outcomes included Boston Carpal Tunnel Questionnaire Symptom Severity Scale and Functional Status Scale, pain severity (0-10 scale), opioid use, health-related quality of life, overall satisfaction, wound satisfaction, and adverse events through 3 months. Propensity score matching was performed to balance patient characteristics between groups. Among 372 matched patients (186 per group), UGCTR was more commonly performed under wide-awake local anesthesia with no tourniquet (85.5% vs 30.1%), had a shorter incision length (5 vs 12 mm), and required less frequent suture closure (11.0% vs 100%). In contrast, procedure time was shorter with ECTR (8 vs 17 minutes). At 3 months, both groups showed significant improvement, with minor differences statistically favoring UGCTR (Boston Carpal Tunnel Questionnaire Symptom Severity Scale, 0.13 points; Functional Status Scale, 0.19 points; pain severity, 0.6 points; health-related quality of life, 0.05 points). Opioid use was lower after UGCTR (10.3% vs 39.7%). Overall satisfaction (92.1% vs 83.6%) and wound satisfaction (93.9% vs 88.3%) were higher with UGCTR. No serious adverse events occurred; nonserious events were less frequent with UGCTR (0% vs 5.9%). UGCTR and ECTR are safe and effective treatments for carpal tunnel syndrome. UGCTR was more commonly performed under wide-awake local anesthesia with no tourniquet and was associated with reduced opioid use and higher overall/wound satisfaction, whereas ECTR was associated with a shorter procedure time. Therapeutic II.

Previous randomized trials and real-world observational studies of electronic alerts for acute kidney injury (AKI) have yielded conflicting results. The applicability of trial findings to routine clinical practice is also contested. Despite this, AKI e-alerts remain widely implemented. Here, we used Regression Discontinuity Design (RDD) to evaluate the real-world causal effect of the nationwide AKI e-alert initiative in Wales. The study encompassed hospital and community-based systems serving 3.1 million adults (aged 18 years and older) residing in Wales, 2016-2020, following implementation of AKI e-alerts across all Welsh health boards, seven using passive alerts and one using interruptive alerts. We assessed outcomes across the e-alert threshold, including mortality, hospital admission/readmission, AKI severity and recovery, documentation of AKI, prescribing, and follow-up monitoring of proteinuria and blood pressure. Among 861,494 hospital and 354,505 community patient encounters, AKI alerts were triggered in 5.8% and 2.0% of cases respectively (mean age 64 years, 54% female). In both settings, AKI alerts led to no significant changes in mortality [complier average treatment effect +1.31% (95% Confidence Interval -3.07, 4.74); +2.07% (-3.44, 6.65)] or admissions/readmissions [+0.13% (-3.82, 4.21); +4.07% (-1.84, 8.27)]. AKI coding was infrequent across both settings. Alerts modestly increased hospital coding [+5.88% (2.22, 7.58)] but had minimal impact on primary care coding post discharge [+0.72% (-0.67, 1.30)] and led to only small improvements in proteinuria and blood pressure monitoring. Findings were consistent across passive and interruptive alert types, clinical settings and subgroups. We found no causal evidence that AKI e-alerts (specifically implemented at a 50% creatinine rise threshold) improved or worsened clinical outcomes in this nationwide real-world evaluation. Consistently poor outcomes, limited documentation and follow-up care, even in the presence of e-alerts, underscore the need for an improved clinical response to AKI.

Personalised medicine has rapidly reshaped the management of urothelial carcinoma, driven by advances in tumour genomics, immune profiling and targeted drug development. This review is timely as multiple biomarker-driven therapies have recently entered routine clinical practice across disease stages, necessitating an integrated appraisal of how precision approaches should be applied and sequenced in contemporary care. Key advances include the expanding role of immune biomarkers beyond PD-L1, such as tumour mutational burden and DNA damage response alterations, to refine the use of immune checkpoint inhibitors. FGFR3 alterations represent the first validated genomic target in urothelial carcinoma, with FGFR inhibitors now established treatment options. Antibody-drug conjugates targeting Nectin-4 and HER2 have demonstrated substantial clinical activity, redefining treatment paradigms in both first-line and refractory settings. In parallel, circulating tumour DNA has emerged as a powerful dynamic biomarker for minimal residual disease detection and adjuvant treatment selection. Urothelial carcinoma has transitioned into a biomarker-driven disease, enabling more precise, biologically informed treatment decisions. Integrating genomic, immunologic and liquid biopsy biomarkers will be essential to optimise patient selection, treatment sequencing and toxicity management, and represents a critical direction for future research and clinical practice.

Artificial intelligence-based gram stain classification: Accuracy and clinical utility in positive blood cultures.

Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) improve glycemic outcomes in people with type 2 diabetes, but their generalizability to routine clinical practice remains uncertain. To evaluate the real-world effectiveness of sustained GLP-1 RA use on haemoglobin A1c (HbA1c) over 1 to 4.5 years, using dipeptidyl peptidase 4 inhibitors (DPP-4is) as an active comparator. Using Danish nationwide registries (2012-2022), we emulated a target trial assessing the glycemic effectiveness of GLP-1 RAs. The primary outcome was the probability of improvement in defined HbA1c categories within 1 year. Longitudinal Targeted Minimum Loss-based Estimation was used to estimate the primary outcome under sustained use of GLP-1 RA and DPP 4i, controlling for baseline and time-varying confounding. We included 16 619 GLP-1 RA initiators and 34 196 DPP-4i initiators, each with 2.8 HbA1c measurements per patient-year. At 1 year, the probability of any HbA1c improvement was 82.7% (95% CI: 82.0% to 83.4%) under sustained GLP-1 RA versus 67.1% (95% CI: 66.5% to 67.6%) under DPP-4i, an absolute difference of 15.7% (95% CI: 14.8% to 16.5%). GLP-1 RA treatment was also associated with a lower all-cause mortality risk, with absolute reductions of 0.4% (95% CI: 0.1% to 0.7%) at 1 year and 1.1% (95% CI: 0.3% to 2.0%) at 3 years. Within the limitations of this nationwide study and the available data, sustained GLP-1 RA therapy provided superior glycemic control and was associated with a modest mortality benefit compared with DPP-4i therapy.

Abstract Background Real-world evidence on the effectiveness and safety of herbal medicines for type 2 diabetes mellitus (T2DM) remains limited despite promising results from controlled studies. This study aimed to evaluate the clinical outcomes of Hyeoldanggaesun-tang, a traditional Korean herbal formulation, in routine clinical practice. Methods This multicenter retrospective chart review included 31 adults with T2DM who received Hyeoldanggaesun-tang continuously for 6 months across four Korean medicine clinics. Clinical and laboratory data were extracted at baseline and at 3 and 6 months. The primary outcome was change in glycated hemoglobin (HbA1c). The secondary outcomes included liver enzymes, lipid profiles, blood pressure, body mass index, and safety indicators. Results Mean HbA1c decreased significantly from 8.85 ± 2.01% at baseline to 7.51 ± 1.32% at 3 months and 7.01 ± 1.18% at 6 months (both p < 0.001), corresponding to a large effect size (Cohen’s d = 1.01 at 6 months). Significant improvements were also observed in liver function markers, including alanine aminotransferase (45.82 ± 17.05 to 40.34 ± 18.32 U/L), aspartate aminotransferase, and gamma-glutamyl transferase (all p < 0.01). Triglyceride levels decreased from 170.25 ± 137.49 to 144.33 ± 110.07 mg/dL ( p < 0.001), while high-density lipoprotein increased and low-density lipoprotein decreased significantly over time. No significant changes were observed in body mass index or renal function. Three patients reported mild adverse events, none of which required treatment discontinuation. Notably, 14 patients reduced or discontinued conventional antidiabetic medications during follow-up while maintaining improved glycemic control. Conclusion Hyeoldanggaesun-tang was associated with clinically meaningful improvements in glycemic control, liver enzymes, and lipid profiles, with a favorable safety profile. These findings support its potential role as a complementary therapy for T2DM and warrant confirmation in prospective randomized controlled trials. Graphical Abstract

Respiratory syncytial virus (RSV) is a leading cause of severe lower respiratory tract infections in early infancy, and the recent introduction of two novel immunoprophylaxis tools-maternal vaccination with the RSVpreF vaccine and infant protection with the long-acting monoclonal antibody nirsevimab-represents a major advancement in RSV prevention. The successful implementation of these strategies depends heavily on pediatricians' awareness, confidence, and readiness to integrate them into routine clinical practice. Evidence from Southern Europe remains limited. This cross-sectional study assessed the knowledge, attitudes, and practices of pediatricians in Crete, Greece, regarding RSV infection and emerging prevention tools. A structured electronic questionnaire was distributed between April and July 2025 to all board-certified pediatricians and pediatric residents registered with the regional medical associations. Among 169 respondents (mean age 46 ± 12.5years; 83.4% women), overall knowledge was high, with a mean score of 89.6 ± 10.0. Knowledge gaps were concentrated in areas related to newly introduced immunoprophylaxis tools, including awareness of RSV monoclonal antibody availability for infants, updated recommendations covering infants up to 6months, and distinctions between palivizumab and nirsevimab. Attitudes toward vaccination were overwhelmingly positive: nearly all participants expressed strong vaccine confidence and adherence to national immunization guidelines. Most pediatricians (78.6%) felt adequately informed about RSV. These findings suggest that pediatricians in Crete possess a strong foundation for integrating new RSV prevention strategies, although targeted educational initiatives-particularly regarding nirsevimab-will be essential to ensure consistent and equitable implementation. The results provide timely insights to support national planning and optimize the rollout of RSV immunoprophylaxis in Greece and comparable settings. What is Known: • RSV is a leading cause of severe respiratory disease in early infancy. • New prevention tools (RSVpreF, nirsevimab) are being introduced into national programs. • Pediatricians' knowledge and confidence strongly influence vaccine uptake. What is New: • Greek pediatricians show high overall RSV knowledge and strong vaccine confidence. • Specific gaps exist regarding nirsevimab and distinctions between immunoprophylaxis tools. • Findings highlight targeted education needs during early implementation of RSV prevention.

Deucravacitinib, an oral TYK2 inhibitor, has demonstrated efficacy and safety in phase III clinical trials for moderate-to-severe plaque psoriasis. However, real-world evidence remains limited. To evaluate the effectiveness and safety of deucravacitinib in adult patients with moderate-to-severe plaque psoriasis treated in routine clinical practice. We conducted a retrospective, single-center, real-world observational study. Consecutive adult patients with moderate-to-severe plaque psoriasis who initiated deucravacitinib between December 2024 and December 2025 were retrospectively identified. At each follow up PASI, DLQI, BSA, NRS pruritus. PASI75, PASI90, and PASI100 response rates were also evaluated. Safety was assessed through adverse event reporting and routine laboratory monitoring. A total of 46 patients completed the 24-week follow-up and were included in the study. Mean PASI decreased from 12.5±3.1 at baseline to 3.2±2.1 at Week 24 (p < 0.001), while mean BSA decreased from 18.0±6.5% to 5.0±3.6% (p< 0.001). NRS pruritus and DLQI also improved significantly over time (both p < 0.001). PASI 75 was achieved by 69.6% of patients at Week 24, while PASI 90 and PASI 100 were achieved by 54.3% and 32.6%, respectively. No serious adverse events or clinically relevant laboratory abnormalities were observed. Acne was the most frequent adverse event, occurring in 4 patients (8.7%), and was mild in all cases. In this real-world study, deucravacitinib showed significant and sustained effectiveness, together with a favorable safety profile, in patients with moderate-to-severe plaque psoriasis. These findings support its role as an effective oral targeted therapy in routine clinical practice.

Background: Anesthesia practice has evolved significantly in recent years with a focus on improving patient safety, enhancing recovery, and reducing perioperative complications. Conventional opioid-based anesthesia is associated with adverse effects such as respiratory depression, postoperative nausea and vomiting (PONV), ileus, and risk of long-term dependence. This has led to increasing interest in opioid-free anesthesia (OFA), along with advancements in artificial intelligence (AI) and personalized drug delivery systems. Objective: This systematic review aims to evaluate the effectiveness, safety, and clinical implications of opioid-free anesthesia, artificial intelligence integration, and personalized drug delivery in modern anesthetic practice. Methods: A systematic review was conducted according to PRISMA guidelines. A comprehensive literature search was performed in PubMed, MEDLINE, Embase, Scopus, and Cochrane Library up to March 2025. Randomized controlled trials, observational studies, and machine learning-based studies involving adult surgical patients were included. Data extraction and quality assessment were performed using standardized tools (Cochrane Risk of Bias and ROBINS-I). A total of 16 studies were included and analyzed using narrative synthesis. Results: Among the included studies, 9 were randomized controlled trials, 3 were observational studies, and 4 were AIbased studies. OFA (n = 7) consistently demonstrated reduced postoperative opioid consumption, lower incidence of PONV, and improved pain control, although variability in protocols was noted. AI-based approaches (n = 5) showed significant improvement in predicting intraoperative complications such as hypotension and hypoxemia, enabling early intervention and better clinical decision-making. Personalized drug delivery systems (n = 4), including target-controlled infusion and closed-loop systems, provided improved anesthesia depth control, reduced variability, and enhanced hemodynamic stability. However, limitations such as lack of standardization, high cost, and limited real-world validation were identified. Conclusion: The integration of opioid-free anesthesia, artificial intelligence, and personalized drug delivery represents a paradigm shift toward safer, more efficient, and patient-centered anesthesia care. While each approach independently improves perioperative outcomes, further research is required to standardize protocols and integrate these technologies into routine clinical practice.

Rock climbing has seen rapid growth in participation worldwide, resulting in an increasing frequency of sport-related injuries encountered in routine clinical practice. Many of these injuries arise from biomechanical demands unique to climbing and demonstrate characteristic imaging features. This review highlights the spectrum of acute and chronic rock-climbing injuries with emphasis on anatomy, injury patterns, and key imaging findings. Upper-extremity injuries predominate, particularly involving the fingers, where annular pulley injuries represent the most common and sport-specific pathology. Additional frequently encountered entities include flexor tendon tenosynovitis, lumbrical muscle tears, wrist synovitis and ligamentous injuries, and stress-related osseous changes of the hand and wrist. Shoulder and elbow abnormalities, often related to repetitive loading or falls, as well as lower-extremity injuries associated with bouldering and specialized maneuvers such as heel hooks, are also reviewed. Ultrasound and MRI each have advantages and disadvantages but ultimately play complementary roles in evaluation. Awareness of climbing-specific injury patterns permits recognition of subtle but important diagnostic findings, guiding management and facilitating safe return to sport.

The bispecific antibody faricimab inhibits vascular endothelial growth factor A (VEGF-A) and angiopoietin-2 (Ang-2), two key mediators in the pathophysiology of neovascular age-related macular degeneration (nAMD), which is characterized by choroidal neovascularization, vascular instability, leakage, and intra/subretinal fluid with consequent vision loss. The aim of our study was to assess the effectiveness of faricimab at week 16 versus baseline in patients with treatment-naïve nAMD managed under real-world conditions in Germany. 45DRY was a retrospective, single-center analysis of consecutive patients with treatment-naïve nAMD initiating faricimab (four monthly injections at weeks 0, 4, 8, and 12). Outcomes were evaluated at baseline and week 16 (± 14days). Theprimary endpoint was change from baseline in central retinal thickness (CRT); secondary endpoints were change in best-corrected visual acuity (BCVA) and presence/absence of intraretinal fluid (IRF), subretinal fluid (SRF), combined IRF + SRF, and subretinal pigment epithelium (sub-RPE) fluid. Analyses were descriptive. A total of 45 eyes from 45 patients were included (mean age 82.1years; 51.1% female). Mean CRT decreased by -140.8μm from 343.1µm at baseline to 202.4µm at week 16 [95% confidence interval (CI) -178.2 to -103.3]. Mean BCVA improved by -0.15 logMAR at week 16. Among eyes with retinal fluid at baseline, IRF resolved in 100% (24/24), SRF in 94.1% (32/34), combined IRF + SRF in 100% (17/17), and sub-RPE fluid in 90% (9/10). Maintenance of fluid-free status was universal in eyes negative at baseline for IRF (21/21), SRF (11/11), and combined IRF + SRF (28/28); sub-RPE fluid remained absent in 100% (35/35). In routine clinical practice, a four-dose faricimab upload per label at the time of study conduct led to a rapid and substantial anatomical drying effect at week 16 with improvement in BCVA and marked CRT reduction. These real-world findings confirm that faricimab rapidly and effectively reduces retinal fluid, in line with post hoc analyses of the pivotal TENAYA and LUCERNE trials.