Robotic surgery is often viewed as a technological frontier, yet its relevance in low- and middle-income countries remains contested. In settings where access to basic surgical care and laparoscopy is still inequitable,...Robotic surgery is often viewed as a technological frontier, yet its relevance in low- and middle-income countries remains contested. In settings where access to basic surgical care and laparoscopy is still inequitable, the pursuit of robotic surgery may appear premature. However, this perspective overlooks a critical insight: the barriers that limit robotic surgery adoption are the same structural constraints that undermine all surgical care delivery. Rather than being dismissed as a low priority, robotic surgery should be understood as a systems-level stress test of health system capacity. Its uneven adoption highlights failures in infrastructure, workforce development, financing, and governance. Addressing these foundational gaps is essential not only for advanced technologies but for achieving sustainable improvements in global surgical equity.
BACKGROUND: Medically high-risk patients with acute cholecystitis may undergo percutaneous cholecystostomy tube (PCT) as an alternative to cholecystectomy. We explored the impact of patient and hospital characteristics o...BACKGROUND: Medically high-risk patients with acute cholecystitis may undergo percutaneous cholecystostomy tube (PCT) as an alternative to cholecystectomy. We explored the impact of patient and hospital characteristics on PCT use. METHODS: We retrospectively reviewed the Maryland HSCRC database (4/1/2022-3/31/2024), including ED patients admitted with acute cholecystitis who underwent inpatient cholecystectomy or PCT. Univariate analyses and mixed-effects logistic regression models were performed to evaluate predictors of PCT placement. RESULTS: Among 8112 patients across 40 Maryland hospitals, 990 (12%) received PCT. Age and clinical severity had the strongest association with PCT use, though sex and insurance status were also significant factors. After accounting for patient characteristics, hospital factors-including hospital size, procedure volume, surgery residency, trauma designation, and Leapfrog grade-were not independently associated with PCT use. CONCLUSION: Patient and hospital characteristics together explain less than 60% of between-hospital variability in PCT use, warranting further investigation into clinical considerations that optimize PCT management.
BACKGROUND: Robotic-assisted coronary artery bypass grafting (CABG) is gaining attention as a viable alternative to traditional CABG with reported benefits secondary to reduced invasiveness of procedure. Despite this, ad...BACKGROUND: Robotic-assisted coronary artery bypass grafting (CABG) is gaining attention as a viable alternative to traditional CABG with reported benefits secondary to reduced invasiveness of procedure. Despite this, advantages, the impact of robotic-assisted CABG on critical outcomes such as graft patency, mortality, and need for reintervention remains incompletely defined. The emergence of artificial intelligence (AI) based large language models (LLMs) promise the ability to rapidly deliver robust secondarily derived data, like that obtained from gold standard human meta-analyses. However, there is a lack of direct comparison between these modalities, preventing adoption of these tools in clinical practice. METHODS: We conduct a dual-phase study, by first performing a rigorous, traditional human-led systematic review and meta-analysis comparing robotic-assisted CABG with traditional CABG with respect to graft patency, mortality, reintervention rates, and operative time. In the second phase, we compare outputs of flagship multimodal LLMs from five major vendors-OpenAI (GPT-4o), Anthropic (Claude Sonnet 4), xAI (Grok 3), Google (Gemini 2.5 Pro), and High-Flyer (DeepSeek-R1)-to the same clinical question, called via public, and domain specific API. Sensitivity analyses were performed excluding studies comparing robotic-assisted CABG with conventional minimally invasive direct CABG (MIDCAB) to address procedural heterogeneity. RESULTS: Meta-analysis of 27 studies found no significant differences between robotic and conventional CABG in reintervention (OR 0.92, 95% CI 0.61-1.38), mortality (OR 0.65, 95% CI 0.38-1.13), or graft patency (P = 0.29). Sensitivity analysis excluding MIDCAB comparator studies did not materially alter these findings. Operative time analyses showed heterogeneous results: pooled estimates suggested shorter times with robotic CABG, but subgroup analyses revealed longer durations for multi-vessel procedures and shorter harvest times for single ITA grafts. Overall, robotic CABG demonstrated comparable outcomes to conventional surgery. CONCLUSIONS: Operative time findings were heterogeneous, with shorter durations observed in single-vessel procedures and longer operative times in multivessel robotic CABG. Domain-specific orchestration-such as that employed by CardioCanon-can substantially improve the clinical fidelity and interpretive quality of AI-generated evidence synthesis in cardiovascular surgery. Human oversight remains essential for robust use of AI and LLM in clinical research.
I'm not surprised that I did not match. I started residency in a preliminary position without a clear sense of why. At the time, I experienced this as a personal failure. Only later did I come to see it as an educational...I'm not surprised that I did not match. I started residency in a preliminary position without a clear sense of why. At the time, I experienced this as a personal failure. Only later did I come to see it as an educational one rooted in a mismatch between how I learned and how medical education measured readiness. As medical schools build classes with a greater breadth of experiences, individualized educational frameworks, like precision medical education, are paramount to the success of each student. They embrace learner variability and help students understand not just what they learn, but also how they learn.
INTRODUCTION: Age is central to differentiated thyroid cancer staging, however its relevance in oncocytic thyroid carcinoma (OTC) remains unclear. We sought to identify a prognostically meaningful age threshold for OTC....INTRODUCTION: Age is central to differentiated thyroid cancer staging, however its relevance in oncocytic thyroid carcinoma (OTC) remains unclear. We sought to identify a prognostically meaningful age threshold for OTC. METHODS: Using SEER (2004-2022) and NCDB (2004-2020), restricted cubic splines (RCS) evaluated potential age prognostic thresholds for OTC; Cox models assessed age in relation to overall survival (OS) in both databases and disease-specific survival (DSS) in SEER. RESULTS: Among 14,624 patients (4114 SEER; 10,510 NCDB), median age was 59 years. RCS demonstrated a linear association between age and survival, indicating that there is no prognostic age threshold. Modeled continuously, age was associated with worse adjusted OS in SEER and NCDB (HR 1.08; 95% CI 1.08-1.09; p < 0.001 for both) and worse adjusted DSS in SEER (HR 1.06; 95% CI 1.04-1.07; p < 0.001). CONCLUSION: No discrete age threshold for survival was identified, cautioning against the use of age-based cutoffs in staging for OTC.
INTRODUCTION: The National Comprehensive Cancer Network (NCCN) recommends that sentinel node biopsy (SNB) be "discussed and considered" for any melanoma patient with a positive SNB (+SNB) risk of >5%. Several guidelines...INTRODUCTION: The National Comprehensive Cancer Network (NCCN) recommends that sentinel node biopsy (SNB) be "discussed and considered" for any melanoma patient with a positive SNB (+SNB) risk of >5%. Several guidelines recommend SNB for transected (positive deep margin) melanomas. METHODS: We examined a prospective University database of patients who underwent SNB for clinically node negative melanoma. Patients with gross residual tumor at the initial biopsy sites were excluded from the analysis of T1 cases. RESULTS: From 2011 to the present, 2142 patients underwent SNB for clinically node negative melanoma. 657 patients had SNB for T1 (thin) melanoma with an overall SNB positivity rate of 3.0%. 387 patients had T1b melanoma (>0.8 mm and/or ulcerated) with a +SNB rate of 4.9% (19/387). 270 had T1a melanoma and underwent SNB for a variety of indications, with a +SNB rate of 0.4% (1/270). In 57 cases transection of a shave biopsy was the only indication for SNB. Of these patients 52% were female, mean age was 60.2 years, mean thickness was 0.6 mm, and the most common tumor site was head and neck (35.1%). Nine (15.8%) had more tumor in the wide excisions but this did not upstage any patient; 4 had only melanoma-in-situ and 5 had residual invasive melanoma with a mean thickness of 0.5 mm. Of the 57, the mean number of SNs removed per patient was 2, and none were positive. CONCLUSIONS: +SNB rates for T1a melanoma fall well below the NCCN cutoff to discuss and consider SNB. Transection alone is not a significant indication for SNB in melanoma when no gross residual tumor is found at the biopsy site.
INTRODUCTION: Factors influencing mortality among pancreatic ductal adenocarcinoma (PDAC) patients who achieve pathologic complete response (pCR) following neoadjuvant therapy have not been previously well studied. METHO...INTRODUCTION: Factors influencing mortality among pancreatic ductal adenocarcinoma (PDAC) patients who achieve pathologic complete response (pCR) following neoadjuvant therapy have not been previously well studied. METHODS: Adult PDAC patients (2006-2021) who received neoadjuvant were identified in the National Cancer Database. Tumor response was categorized as pCR if final specimen was pT0N0. Patients with positive margins and stage IV disease were excluded. RESULTS: Of 13,089 eligible patients, there were 207 patients who achieved pCR. The 3-year overall survival was 75% [69-81] for the entire cohort and did not differ significantly by clinical stage at diagnosis. Increased length of stay was the only factor associated with increased risk of mortality (HR 1.05 [95% CI: 1.02-1.09, P < 0.01]) in multivariable analysis. CONCLUSIONS: Among PDAC patients who achieve pCR, postoperative morbidity rather than initial disease stage appears to be the primary driver of long-term survival, informing prognostication for this unique subset of patients.
BACKGROUND: Oncoplastic breast surgery (OBS) increases eligibility for breast conserving surgery, though its impact on satisfaction and quality of life remains unclear. Most patients undergo level 1 OBS with removal of <...BACKGROUND: Oncoplastic breast surgery (OBS) increases eligibility for breast conserving surgery, though its impact on satisfaction and quality of life remains unclear. Most patients undergo level 1 OBS with removal of <20% of breast volume. However, variable technical approaches may influence patient reported outcomes (PRO). METHODS: Patients undergoing standardized (sOBS-1) and advanced (aOBS-1) level 1 OBS were prospectively evaluated using the BREAST-Q (BQ) questionnaire pre-operatively and one year post-operatively. Domains included Satisfaction with Breasts (SatBr), Physical Well-being (PhWb), and Psychosocial Well-being (PsyWb). Linear regressions assessed relationships with BQ scores. RESULTS: Of 58 patients, 43 underwent sOBS-1 and 15 aOBS-1. Groups were similar in age and BMI, though aOBS-1 patients had larger tumours (median 21 vs 12 mm; p = 0.0001). Tumor size negatively impacted SatBr (p = 0.018). No significant differences were found between groups across all BQ domains. CONCLUSION: Despite larger tumours, aOBS-1 yielded comparable PROs to standardized approaches.
INTRODUCTION: The purpose of this study was to compare preoperative HIDA scans, ultrasound, and patients' symptoms with final surgical pathology on patients who underwent cholecystectomy. METHODS: A retrospective chart r...INTRODUCTION: The purpose of this study was to compare preoperative HIDA scans, ultrasound, and patients' symptoms with final surgical pathology on patients who underwent cholecystectomy. METHODS: A retrospective chart review was conducted on patients who underwent cholecystectomy between 1/1/2020 and 12/31/2022 at our local hospital. Data were collected on patient demographics, preoperative symptoms, gallbladder ultrasound results, HIDA scan results, and pathology results. RESULTS: A total of 116 patients met the study inclusion criteria. HIDA scan findings had a sensitivity of 80.4%, a specificity of 33.3%, and an AUC of 0.594, P = .482. For those with normal findings on HIDA scan, 83.3% had a pathological finding of chronic cholecystitis, 44.4% had cholesterolosis, and 26.3% had cholelithiasis. CONCLUSIONS: Our findings suggest that the benefit of the HIDA scan appears to be in the presence of positive symptomology and negative ultrasound findings as HIDA scans are a relatively weak discriminator of positive pathology.
BACKGROUND: Colorectal cancer (CRC) carries a high recurrence risk. Aspirin has been proposed for secondary prevention, but its benefit remains uncertain. This systematic review and meta-analysis evaluated aspirin's impa...BACKGROUND: Colorectal cancer (CRC) carries a high recurrence risk. Aspirin has been proposed for secondary prevention, but its benefit remains uncertain. This systematic review and meta-analysis evaluated aspirin's impact on disease-free survival (DFS) and overall survival (OS). METHODS: A systematic search of four databases (PubMed, Embase, Scopus, the Cochrane Library) was conducted from inception to January 2025 using predefined inclusion and exclusion criteria. Screening and data extraction were performed independently. Study quality was assessed using RoB 2 and the Newcastle-Ottawa Scale. Ten studies were included, comprising retrospective cohorts, population-based cohorts, prospective observational analyses, and Phase III randomized controlled trials (RCTs). A random-effects meta-analysis was conducted to pool effect sizes as odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was quantified using I and τ, and sensitivity analyses included leave-one-out testing. All analyses followed PRISMA guidelines. RESULTS: Ten studies were included. Pooled analyses of observational studies showed no statistically significant improvement in OS (OR 0.92, 95% CI 0.78-1.08) or DFS (OR 0.90, 95% CI 0.74-1.08) among aspirin users. Considerable heterogeneity and inconsistency were observed across studies. RCTs likewise demonstrated no clear survival benefit, with effect estimates close to unity. Safety data were limited and variably reported, precluding firm conclusions regarding adverse outcomes. CONCLUSION: Current evidence does not support aspirin as adjuvant therapy for secondary prevention in CRC. Future research should target biomarker-defined subgroups for potential benefits.
BACKGROUND: Military-civilian partnerships (MCPs) have served as a cornerstone of U.S. medical readiness. Active-duty surgeon case volumes have dramatically decreased over the last two decades, making these relationships...BACKGROUND: Military-civilian partnerships (MCPs) have served as a cornerstone of U.S. medical readiness. Active-duty surgeon case volumes have dramatically decreased over the last two decades, making these relationships more crucial than ever. METHODS: A review of formal partnership agreements between Madigan Army Medical Center (MAMC) and regional civilian health systems from 2019 to 2024 to further characterize MCPs. RESULTS: Eighteen agreements were identified, comprising three administrative structures: Medical Training Agreements (MTAs, n = 14), External Resource Sharing Agreements (ERSAs, n = 3), and one National Defense Authorization Act (NDAA). These agreements supported ten disciplines, with general and trauma surgery most frequently represented. Separate GME MCPs provided complex surgical volume in 15 surgical specialties. CONCLUSIONS: MCPs in the South Puget Sound region form a comprehensive readiness network bridging military and civilian healthcare systems. Expansion of MCPs through improved interoperability, standardized evaluation, and additional partnerships remains essential for a resilient, dual-use healthcare infrastructure.
Mass casualty events and public health emergencies consistently challenge regional healthcare systems, requiring integrated coordination to ensure patient care and resource management during surge conditions. Regional Me...Mass casualty events and public health emergencies consistently challenge regional healthcare systems, requiring integrated coordination to ensure patient care and resource management during surge conditions. Regional Medical Operations Coordination Centers (RMOCCs) serve as a critical, systems-level approach to managing medical surges. The San Antonio RMOCC, established by the Southwest Texas Regional Advisory Council (STRAC), offers a proven, sustained model, having successfully managed responses to natural disasters, civil unrest, and the COVID-19 pandemic. This paper details the historical, regulatory, and operational context of the San Antonio RMOCC and presents a scalable RMOCC framework, providing recommendations for development, implementation, and sustainment of RMOCCs across the United States. The framework emphasizes key components for success, including effective coalition integration, sustainable funding strategies, strong system leadership, and buy-in from diverse partners. Through implementation of this framework, other regions may develop similar response capabilities to improve regional surge preparedness and emergency response.