Publications by Year: 2026

UNLABELLED: Children with cerebral palsy (CP) undergoing orthopaedic surgery require thorough preoperative evaluation to enhance outcomes and minimize risks. This comprehensive review covers various considerations. Each part of the preoperative assessment is explained, emphasizing the importance of a tailored approach to address the specific needs and complexities of children with CP. Anesthesia considerations include the pulmonary, cardiovascular, and gastrointestinal systems to reduce perioperative complications. Neurological issues, such as seizure management and medication interactions, are detailed, along with respiratory problems like aspiration and poor airway clearance, gastrointestinal concerns, nutritional status, and bowel management. Vascular considerations focus on planning access and volume resuscitation before major orthopaedic procedures. Skin-related issues, including pressure ulcers and wound healing, require preventive strategies and careful postoperative care. Other factors addressed include urinary tract problems, deep vein thrombosis risks, blood loss management, pain control, anesthesia challenges, and psychological effects. This review highlights the importance of teamwork, patient-centered care, and thorough planning to ensure the best possible outcomes for children with CP undergoing orthopaedic surgery.

KEY CONCEPTS: (1)Children with cerebral palsy (CP) who are preparing for orthopaedic surgery need a thorough preoperative assessment.(2)A thorough preoperative assessment is crucial to make sure that any surgical procedure is customized to the child's specific functional needs and that the risks and benefits are thoughtfully evaluated.(3)Multidisciplinary care and focusing on patient-centered outcomes are crucial when deciding to pursue orthopaedic surgery in this high-risk population.(4)Effective communication with the child's caregivers and health care team is vital to ensure coordinated care and a clear plan for both preoperative and postoperative management.

A rudimentary horn is a type of congenital uterine anomaly associated with a unicornuate uterus. Rudimentary horn pregnancies (RHPs) are extremely rare and the majority of cases result in second trimester rupture necessitating emergent laparotomy with associated high maternal morbidity and delivery of a previable fetus. We report the case of a 33-year-old G5P0131 female who presented at 15 weeks and 4 days gestational age with pelvic and back pain and imaging favoring an abdominal pregnancy. The patient underwent an exploratory laparotomy with left salpingectomy and excision of an unruptured extrauterine pregnancy that was confirmed to be an RHP on pathologic examination. Postsurgery review of the imaging demonstrated several features consistent with the diagnosis of an RHP that were not initially identified. Furthermore, the patient's medical and surgical histories were notable for several risk factors associated with congenital uterine anomalies that should have heightened the clinical suspicion for an RHP. This case emphasizes how increased familiarity with the risk factors and imaging findings associated with rudimentary horns and RHPs may lead to an earlier and more accurate diagnosis, more timely and appropriate treatment, and ultimately a reduction in maternal and fetal morbidity and mortality.

BACKGROUND: Traumatic arthrotomies are rare, urgent injuries that carry high presumed risks for joint contamination and septic arthritis (SA). Most of these injuries occur in the knee. Like open fractures, treatment typically involves prompt antibiotic administration followed by surgical irrigation, debridement, and closure. Unlike open fractures, there is sparse evidence guiding pediatric arthrotomy management. This study aimed to characterize the demographics, clinical management, and outcomes of pediatric traumatic arthrotomies of the knee and other joints.

METHODS: Children with confirmed traumatic arthrotomy diagnoses admitted to the emergency department at a level 1 pediatric trauma center between 2013 and 2023 were retrospectively reviewed. Patient demographics, clinical characteristics, and outcomes were summarized using descriptive statistics. Postoperative complications were analyzed, along with 95% confidence intervals calculated using the Clopper-Pearson method.

RESULTS: Our cohort consisted of 36 patients (75% male, 68% White, average age 10 years, 58% privately insured). Traumatic arthrotomies most frequently resulted from falls (44%) and occurred in the knee joint (89%). The median time from admission to the operating room was 9 h (r, 2-45), with antibiotics initiated after a median of 4 h (r, 0-16) and continued for a median of 6 d (r, 0-24). Most patients (92%) underwent open irrigation and debridement with a median irrigation volume of 6 L (r, 1-9 L), and drain placement was used in 8 patients (22%). Forty-four percent of patients with a knee arthrotomy had an associated deep structure injury requiring repair. Four patients (11%) required reoperation for complex soft-tissue management, and three (8%) experienced noninfectious complications. Two patients developed superficial infections (5%); no cases of deep infection/SA were observed. Median duration of joint immobilization was 14 d (r, 0-59), and median time to return to full range of motion was 45 d (r, 6-93). Median time to clearance for full activity was 40 d (r, 12-153).

CONCLUSIONS: Following a traumatic arthrotomy, most children achieve complete, uncomplicated recoveries. We report an absence of deep infection and a low superficial infection rate, none of which occurred in the knee. However, surgeons should remain vigilant in assessing for associated soft-tissue injuries.

KEY CONCEPTS: (1)In this investigation, we found that there is a very low risk of deep infection or septic arthritis in children with traumatic arthrotomies (0% in our series) when applying the standard of care of timely antibiotic administration and surgical irrigation and debridement of the joint.(2)There was a high rate of structural soft-tissue injury that required repair (i.e., patellar/quadriceps tendon laceration) in traumatic arthrotomies of the knee.(3)Most children experience full recovery and return to sport around 6 weeks after traumatic arthrotomy.

LEVEL OF EVIDENCE: Level IV, case series.

BACKGROUND: Nails in the elderly undergo several structural changes related to aging with respect to surface, thickness, color, and growth pattern. The present study explores the potential association between nail alterations and zinc levels in this population.

METHODS: A total of 64 subjects aged ≥60 years with or without nail changes were recruited from the Dermatology and Venereology Outpatient Clinic at Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Their nail features were observed clinically and evaluated utilizing dermoscopy, and nail clippings weighing a total of 200 milligrams were collected from each subject for nail zinc concentration measurement. Appropriate statistical tests were employed to determine the relationship between nail zinc levels and the structural alterations, as well as the patients' comorbidities and medications, at a significance level of 0.05.

RESULTS: Most subjects in our study showed altered nail profiles in multiple digits (75.0%) with a predilection for toenails (62.3%), and the first toenail was primarily affected. The commonest dermoscopic features displayed in altered nails include nail plate pigmentation (n = 64), distal edge thickening (n = 39), and surface changes (n = 34). The average nail zinc concentration was lower in the elderly with nail changes than in those without, albeit with no statistically significant differences (p = 0.687). Subgroup analyses according to comorbidities (hypertension, diabetes mellitus type 2, and dyslipidemia) and medications (antihypertensives, antidiabetics, antidyslipidemic drugs, and anticonvulsants) also exhibited no discrepancies.

CONCLUSIONS: This study highlights the complex interactions among nail structural changes, zinc levels, comorbidities, and medications; hence, further research is warranted to obtain a deeper understanding.

Diffuse podocytopathy (DP) is a clinical and pathological entity, which comprises minimal change disease and primary focal segmental glomerulosclerosis (FSGS). It is characterized by diffuse podocyte foot process effacement resulting in nephrotic syndrome. Cumulative evidence supports that DP is a complex disease caused by circulating permeability factors. Following kidney transplantation, DP may recur and severely compromise graft survival. However, prior studies aiming to define immune and genetic factors implicated in disease recurrence have been limited by small cohorts and lack of utilizing stringent criteria to define DP. In this report, we briefly review the important advances made in understanding genomic and permeability factors involved in DP in the native kidney and in the transplant setting, focusing on anti-nephrin antibodies. We stress the importance of applying stringent criteria to define patients at risk of post-transplant recurrence and share our experience in a cohort of 281 consecutive kidney transplant recipients with native kidney failure attributed to FSGS or other forms of DP. Applying strict clinicopathologic criteria combining nephrotic syndrome and diffuse foot process effacement at the time of native kidney biopsy to define DP markedly increased recurrence rate from 9% to 36%. Excluding selected patients with monogenic forms of FSGS and those with high-risk APOL1 genotypes further increased recurrence rate to 54%. In conclusion, an accurate diagnosis of DP in the native kidney is crucial to further our understanding of genomic and immunologic predictors of DP recurrence and to ultimately support the development of prophylactic or therapeutic regimens to improve allograft outcomes.

BACKGROUND & AIMS: The importance of maintaining optimal lipid levels across young adulthood in preventing metabolic dysfunction-associated steatotic liver disease (MASLD) is unclear. This study aimed to evaluate associations of lipid profiles through young adulthood with midlife MASLD risk and assess the mediating effect of epigenomic biomarkers.

METHODS: This study included 2,577 participants from the Coronary Artery Risk Development in Young Adults study using data from baseline (Year 0 [Y0], 1985-1986) to Y25 (2010-2011). Time-weighted average (TWA) lipid exposures during young adulthood (ages 18-39 years) were estimated using up to seven measurements (Y0-Y20). Non-contrast abdominal CT scans were performed to measure steatosis at Y25 (mean age, 50 years). Blood DNA methylation (DNAm) was measured at >840,000 methylation sites at Y20. A total of 492 MASLD cases were identified.

RESULTS: Compared with optimal TWA lipid levels, multivariable-adjusted odds ratios of developing MASLD were 3.26 (95% CI 2.51-4.25) for abnormal triglycerides (≥100 vs. <75 mg/dl), 2.39 (95% CI 1.73-3.31) for high-density lipoprotein cholesterol (<40 [men]/50 [women] vs. ≥60 mg/dl), 1.77 (95% CI 1.37-2.30) for non-high-density lipoprotein cholesterol (≥150 vs. <130 mg/dl), 1.74 (95% CI 1.19-2.51) for apolipoprotein B (≥110 vs. <90 mg/dl), 1.43 (95% CI 1.08-1.90) for low-density lipoprotein cholesterol (≥130 vs. <100 mg/dl), and 1.39 (95% CI 1.07-1.81) for total cholesterol (≥200 vs. <180 mg/dl). These associations were consistent across sex, race, alcohol intake, and genetic susceptibility. DNAm markers located in CPT1A, ABCG1, and DHCR24 genes mediated 2.9%-15.4% of observed associations.

CONCLUSIONS: Cumulative exposure to abnormal lipids through young adulthood contributes to MASLD development in midlife, with these associations partially mediated by lipid-associated DNAm.

IMPACT AND IMPLICATIONS: Dyslipidemia is a major modifiable risk factor for metabolic dysfunction-associated steatotic liver disease (MASLD). Evidence largely focuses on mid-to-late-life lipid levels, while the impact of cumulative lipid exposure through young adulthood on midlife MASLD risk remains unclear. Using seven repeated lipid measures in a longitudinal observational study, we found that cumulative abnormal lipid exposure during young adulthood (ages 18-39 years) strongly predicted MASLD risk over a 25-year follow-up, outperforming single-visit measures. DNA methylation markers in CPT1A, ABCG1, and DHCR24 mediated 2.9%-15.4% of observed associations. Our findings underscore the value of assessing cumulative lipid exposure for midlife MASLD risk stratification and highlight epigenomic mediators as potential targets to strengthen MASLD prevention strategies.

STUDY OBJECTIVES: While recovery sleep can ameliorate the negative impacts of total sleep deprivation (TSD) on cognitive functioning, the effects of post-TSD sleep on different forms of emotional functioning remain unknown. Here, we investigated the effects of TSD and post-TSD recovery sleep on emotional memory processing.

METHODS: Participants viewed scenes with negative or neutral central objects overlain on neutral backgrounds. The scene components were then presented separately for recognition testing. Participants in the TSD (n = 46) and Sleep (n = 22) conditions encoded the scenes the morning after the sleep manipulation ( 10:00) and recognition memory was tested for half of the scene components after a short delay (Recog_1,  10:45). Twenty of the TSD participants then received a 90-min nap opportunity (TSDNap). All participants then completed a second recognition test on the remaining images (Recog_2,  14:00).

RESULTS: At Recog_1, all TSD participants showed worse overall memory compared to sleep participants. Specifically, memory was significantly worse for every scene component except neutral objects during Recog_1. At Recog_2, while memory deteriorated further for all scene components in the TSDNoNap group, the TSDNap group showed no memory decline and had improved memory for negative objects, matching the sleep group at Recog_2.

CONCLUSIONS: Post-TSD recovery sleep preserves and restores memory functioning to the level seen in typically rested individuals. But extending TSD leads to continued memory deterioration, highlighting the importance of sleep in healthy emotional memory functioning. This paper is part of the Festschrift in honor of Dr. Robert Stickgold.

COVID-19 has affected millions of individuals worldwide, yet the neuro-ophthalmic consequences among survivors remain incompletely characterized. In this case report, we describe a case of unilateral optic neuritis identified in the emergency department using ultrasound in a previously healthy young woman shortly after confirmed SARS-CoV-2 infection. This case highlights the importance of recognizing neuro-ophthalmic sequelae of COVID-19, outlines the diagnostic evaluation, and demonstrates clinical improvement with corticosteroid therapy.

Background and objective Large language models (LLMs) are increasingly being explored as adjuncts to medical education; however, comparative data on the performance and error patterns of newer models on standardized licensing-style questions remain limited. This study evaluated two advanced large language models (LLMs) - Gemini-Pro and GPT-4 Turbo - on the National Board of Medical Examiners (NBME) Step 1-style multiple-choice questions to assess accuracy, reasoning quality, and common failure modes relevant to exam preparation and clinical reasoning training. Methods A total of 112 NBME Step 1 questions were collected; seven image- or table-dependent items were excluded, yielding 105 text-only questions. Prompts were standardized to include the clinical stem, query, and answer choices and were submitted via Python API to Gemini-Pro and GPT-4 Turbo. Outputs were independently adjudicated by two third-year medical students and one board-certified physician using binary accuracy scoring and structured evaluation of reasoning features (logical reasoning, internal information use, and external knowledge application). Incorrect responses were categorized as logical, informational, or statistical errors. Comparative analyses included raw accuracy calculations and chi-square testing of reasoning-feature distributions. Results GPT-4 Turbo achieved 90.99% accuracy on the January 2024 NBME Step 1 question set, substantially outperforming Gemini-Pro (54.46%). GPT-4 Turbo demonstrated fewer errors overall, with lower logical (16%), informational (4%), and statistical (4%) error rates compared with older baselines reported in the study (e.g., GPT-3.5 logical errors 42%). GPT-4 Turbo incorporated external information in 76% of correct responses versus 25% for Gemini-Pro, and differences in performance metrics between GPT-4 Turbo and Gemini-Pro were statistically significant (p < 0.05). Conclusions GPT-4 Turbo markedly outperformed Gemini-Pro on text-based NBME Step 1 questions, showing higher accuracy, stronger reasoning consistency, and fewer logical/informational failures. These findings support GPT-4 Turbo's potential role as a high-yield supplementary tool for Step 1-style learning and feedback, while underscoring the need for continued refinement and cautious, supervised integration of LLMs into medical education, given persistent (though reduced) error rates.