Medicine

Background Postoperative nausea and vomiting (PONV) remains a frequent and distressing complication after gynecologic laparoscopic surgery, with residual incidence approaching 30-40% despite contemporary multimodal antiemetic prophylaxis. Transcutaneous auricular vagus nerve stimulation (taVNS) is a noninvasive neuromodulation technique that activates auricular vagal afferents projecting to brainstem nuclei implicated in emetic reflexes. We present the protocol of a randomized trial to evaluate taVNS as an adjunctive, nonpharmacologic strategy to reduce PONV in this high-risk population. Methods This single-center, prospective, randomized, double-blind, sham-controlled, parallel-group superiority trial will enroll 146 adult women undergoing elective gynecologic laparoscopy under general anesthesia. Participants will be randomized 1:1 to active taVNS or sham stimulation, with stratification by Apfel risk score ([≤]2 vs. [≥]3). Two 30-minute sessions will be delivered: one beginning 30 minutes before anesthesia induction and another 30 minutes after arrival in the post-anesthesia care unit. The primary outcome is the incidence of PONV within 48 hours postoperatively. Secondary outcomes include nausea severity (11-point numerical rating scale), time to first PONV episode, number of vomiting/retching episodes, rescue antiemetic use, postoperative pain intensity, cumulative opioid consumption (morphine equivalents), Quality of Recovery-15 scores at 24 and 48 hours, and gastrointestinal recovery indices. Analyses will follow intention-to-treat and per-protocol principles; missing data will be addressed via multiple imputation. Conclusions This trial aims to provide rigorous evidence on the efficacy and safety of perioperative taVNS for PONV prevention in women undergoing gynecologic laparoscopy. If proven effective, taVNS could be integrated into enhanced recovery after surgery (ERAS) pathways as a mechanistically grounded, nonpharmacologic adjunct to standard antiemetic regimens. Trial registration Chinese Clinical Trial Registry ChiCTR2600115965 (prospectively registered).

Background: Knowledge translation (KT) is essential for ensuring that research evidence informs policy and practice. However, little is known about researchers' intentions to engage in KT activities or their relationship with conventional bibliometric indicators. This study aimed to (1) assess researchers intentions to engage in KT activities using a questionnaire informed by the Theory of Planned Behavior (TPB), and (2) examine the association between these intentions and individual bibliometric indicators. Methods: A cross-sectional survey was conducted among faculty members at Tehran University of Medical Sciences. A questionnaire informed by selected constructs of the TPB was developed to assess researchers intentions to engage in activities across the seven components the action cycle of Knowledge-to-Action (KTA) framework. The instrument was validated through several rounds of expert review and then with a sample of potential participants. Bibliometric indicators (H-index, Number of Publications, Number of Citations, First-Author Publications, Corresponding Authorship, International Publications and Self-Citations) were extracted from the national academic registry. To assess representativeness, bibliometric characteristics of respondents were compared with those of a random sample of non-respondents drawn from the same registry. Confirmatory Factor Analysis (CFA) validated the intention construct, and Structural Equation Modeling examined associations with demographic and bibliometric variables. Results: A total of 143 researchers participated. Intention scores were highest for adapting knowledge to local contexts and identifying barriers and facilitators, and lowest for monitoring and sustaining knowledge use. CFA supported a unidimensional intention construct with favorable model-fit indicators. No bibliometric indicator was significantly associated with KT intention. Age was the only significant predictor. Respondents had stronger bibliometric profiles than non-respondents, indicating potential non-response bias. Conclusions: Researchers reported relatively strong intentions to engage in KT, but these intentions were not associated with conventional bibliometric indicators. Age was the only significant predictor. Overall, findings suggest that traditional academic metrics may not reflect KT intentions and highlight the need to strengthen institutional incentives for KT.

Background: Emergency conversion from labor epidural analgesia to Category I cesarean section leaves little time for epidural top-up to produce a surgical block. We examined whether low-dose intravenous esketamine could provide short-term bridging analgesia and sedation while maintaining maternal hemodynamics, oxygenation, and early neonatal safety. Methods: In this randomized study, parturients requiring Category I cesarean section after labor epidural analgesia received either esketamine 0.15 mg/kg or normal saline 1 min before skin incision, together with epidural alkalinized lidocaine. The primary outcome was the longitudinal change in maternal systolic blood pressure during the 20-min observation window. Secondary outcomes included heart rate, SpO2, intraoperative pain, surgeon satisfaction with muscle relaxation, Ramsay sedation score, and neonatal Apgar scores. We analyzed repeated continuous outcomes with linear mixed-effects models and repeated binary outcomes with generalized estimating equations. The single post-administration Ramsay outcome was analyzed using logistic regression. Apgar scores were summarized descriptively using medians, interquartile ranges, and counts.Results: We analyzed 55 parturients, 31 in the esketamine group and 24 in the normal saline group. Esketamine did not meaningfully alter the systolic blood pressure trajectory. Heart rate and SpO2 showed broadly similar patterns between groups, with no signal of esketamine-related respiratory deterioration. The esketamine group had lower odds of intraoperative pain at 5, 15, and 20 min and a higher probability of target Ramsay sedation. Surgeon satisfaction with muscle relaxation showed no clear between-group difference. Apgar scores remained high in both groups. Conclusion: Low-dose intravenous esketamine 0.15 mg/kg may be a practical bridging adjunct during emergency conversion from labor epidural analgesia to Category I cesarean section. It improved early pain control and target sedation without a clear adverse signal in systolic blood pressure, heart rate, oxygenation, or early Apgar scores. Trial Registration: Chinese Clinical Trial Registry, ChiCTR2600121948; retrospectively registered.

INTRODUCTION Large language models (LLMs) have demonstrated substantial performance on medical licensing and board examinations, but their application to anesthesiology remains less well studied. Prior evaluations have not compared current-generation models from different developers or assessed performance on figure-dependent questions that earlier models lacked the capability to interpret. This study evaluates the performance of two current-generation LLMs on a comprehensive anesthesiology in-training examination (ITE) review question bank, including figure-dependent items. METHODS A total of 1,001 single-best-answer questions from an anesthesiology ITE review text, spanning 11 content chapters, were administered to Claude Opus 5 and GPT-5.6. No questions were excluded. Each item was presented once in a fresh, stateless context with no tool access, retrieval, answer key, or explanation provided in the prompt. Performance was analyzed by question format, and all 27 figure-dependent items were administered with their published figures supplied. Accuracy between models was compared using McNemar's test. RESULTS Claude Opus 5 answered 947/1,001 items correctly (94.6%; 95% CI, 93.0-95.8), and GPT-5.6 answered 946/1,001 correctly (94.5%; 95% CI, 92.9-95.8); the difference was not significant (McNemar p=1.00). Accuracy was similar across most question formats. On standard questions, accuracy was 94.3% and 94.6% for Claude Opus 5 and GPT-5.6, respectively; on the 18 figure-based questions with figures supplied, accuracy was 94.4% and 83.3%, respectively; and both models achieved 100% accuracy on image-option items. Withholding figures from the same 18 figure-based questions reduced pooled accuracy from 88.9% to 52.8% (exact McNemar p=0.03 and p=0.04 for Claude Opus 5 and GPT-5.6, respectively). The models agreed on 957/1,001 items (95.6%). Of the 33 items both models answered incorrectly, they selected the same incorrect option on 32 (97%). DISCUSSION Current-generation LLMs achieved approximately 95% accuracy, substantially improving on our prior results with earlier-generation models and placing both models within the highest band of the ITE normative framework, corresponding approximately to the 99th percentile across training levels. By comparison, our prior work with previous models placed ChatGPT-3.5 at the 52nd, 3rd, and 1st percentiles and ChatGPT-4.0 at the 99th, 95th, and 84th percentiles across increasing levels of training. Multimodal capability now permits successful interpretation of many figure-dependent questions, although performance declines markedly when required visual information is unavailable, and highly concordant errors remain. These findings support an increasingly promising role for LLMs as accessible, on-demand educational adjuncts for anesthesiology trainees, provided complete source material is supplied and outputs are critically reviewed.

Objective Nurses' specific medication-administration double-check procedures vary widely; while independent double-checks (IDCs) are considered effective and recommended, they are implemented insufficiently in practice. This study aimed to classify these procedures by their component features and determine which features nurses consider desirable and perceive as implemented in clinical practice. Design Cross-sectional web-based vignette study Setting, participants, and methods Nurses working in Japanese hospitals or clinics participated in this study, for which we created 84 scenarios by combining checking procedures' features, including independence between checkers, across the calculation, preparation, and administration stages. For each scenario, participants self-reported the desirability of the procedure and its perceived implementation frequency in their clinical setting. Linear mixed-effects models assessed associations between checking-procedure features and each rating, and McNemar's test assessed discrepancies between desirability and implementation frequency for IDC. Primary outcome Associations between double-check procedures' features and their desirability and implementation frequency, and the alignment between desirability and implementation frequency for IDC Results Of 534 respondents, 265 were analyzed after prespecified attention-check exclusions. Independent checking was positively associated with desirability (b=0.304, 95% CI [0.255, 0.353], p<0.001), perceived implementation frequency for high-risk medications (b=0.140, 95% CI [0.080, 0.200], p<0.001), and non-high-risk medications (b=0.083, 95% CI [0.022, 0.143], p=0.008). Only 22.5% of nurses perceived IDC as the most frequently implemented procedure during the calculation stage. Moreover, 23.4% rated IDC as the most desirable, but did not report it as the most frequently implemented, whereas 8.1% showed the reverse pattern (OR=2.89, 95% CI [1.69, 4.94], p<0.001). Conclusions Although independence, a key feature of IDC, was reflected in nurses' desirability ratings and perceived implementation frequency, IDC was not the most frequently implemented checking procedure, relative to others. Implementing IDC may require not only promoting understanding of its significance but also establishing work protocols and organizational environments that enable independent checking.

Objectives To evaluate discrepancies between radiologists and referring physicians in the interpretation of diagnostic probabilities conveyed by common Japanese expressions used in radiology reports. Materials and Methods Fifteen expressions commonly used to convey diagnostic probabilities in radiology reports were selected by five attending radiologists. An anonymous online survey was distributed to 26 radiologists and 33 referring physicians at a single institution. Participants assigned a diagnostic probability (from 0% to 100% in 10% increments) to each expression. Differences in median probabilities between radiologists and referring physicians were analyzed using the Mann-Whitney U test. Variability in interpretation was assessed using interquartile range (IQR), with IQR [&ge;] 30% defined as substantial variability. Results All radiologists (26/26) and 97% of referring physicians (32/33) completed the survey. Seven of the 15 expressions showed statistically significant differences in interpretation between radiologists and referring physicians: "c/w" (80% vs. 60%; p = 0.031), the Japanese equivalents of "present" (100% vs. 100%; p = 0.024), "suspect of" (80% vs. 70%; p = 0.007), "possibly" (50% vs. 70%; p < 0.001), "unlikely" (10% vs. 10%; p = 0.022), "cannot be ruled out" (25% vs. 40%; p < 0.001), and "not inconsistent with" (80% vs. 90%; p = 0.008). Substantial variability in interpretation (IQR [&ge;] 30%) was observed for four expressions: "cannot be ruled out" (IQR, 10%-40%), "s/o" (IQR, 60%-90%), "c/w" (IQR, 50%-90%), and "not inconsistent with" (IQR, 70%-100%). Conclusion This study revealed that nearly half of the Japanese expressions commonly used to convey diagnostic probabilities were interpreted differently by radiologists and referring physicians. These discrepancies highlight the need for a standardized lexicon to improve clarity and consistency in radiology reporting.

Background A culture of patient safety is a significant determinant of healthcare quality and the prevention of patient harm. The objective of this study was to evaluate patient safety culture among healthcare workers at a tertiary-care hospital in India using the Indian-adapted Hospital Survey on Patient Safety Culture (I-HSOPSC 2.0). Method The survey was descriptive and cross-sectional, carried out among 96 healthcare practitioners, comprising 32 doctors, 32 nurses, and 32 allied health professionals. Also, a validated version of the Hospital Survey on Patient Safety Culture (I-HSOPSC 2.0) was used to measure patient safety culture in India. Descriptive statistics, Shapiro-Wilk test, Kruskal-Wallis test, Fishers exact test, and positive response rate analysis were used for the data analysis. Result The overall patient safety culture score was 3.72 {+/-} 0.52, indicating a positive view of patient safety culture. In terms of domains, Communication about Errors, Management Support for Patient Safety, and Teamwork scored highest, while Staffing, Work Pace, and Response to Errors scored lowest. Considerable discrepancies were observed across professions, with allied health professionals giving more favourable answers than nurses. Conclusion Overall, the culture around patient safety was good, but areas such as staffing, pace of work, and error response need targeted attention to sustain patient safety and improve the quality of care in healthcare services.

Abstract Background: Large language models (LLMs) are increasingly explored as adjunct tools in graduate medical education, but their reliability for answering discipline-specific certification examinations remains incompletely characterized. In dentistry in China, the national dental examination serves as a milestone for stomatology trainees. Prior studies predominantly rely on single metric, limiting reproducibility and granularity. Objective: To systematically evaluate the performance of five LLMs in answering the national standardized training examination for dental residents. Method: A total of 1,318 questions covering the six dentistry disciplines were selected. Five LLMs (DeepSeek-V3, DeepSeek-R1, Qwen3-32B, Claude 3.5, and GPT-4o) were evaluated via a single-response protocol on the Dify-based Chatflow framework. Performance combined human verification with automated scoring using the Retrieval-Augmented Generation Systems (RAGAS) framework across seven dimensions. Tasks involving question classification, key-point categorization, and instructional requirement summarization were designed to enable a horizontal comparison of models' cognitive capabilities, assessed using inter-model consistency scores. Results: DeepSeek-R1 achieved the highest correct choice rate (80.90%, p < 0.001) and answer correctness score (0.853, p < 0.001), significantly outperforming the others. All models exhibited limitations, including information insufficiency, redundancy, and hallucination-related issues (lowest 44.20% in DeepSeek-R1). In classification and summarization tasks, Claude 3.5 showed higher consistency scores (186/181) than Qwen3-32B (152/151). Conclusion: Evaluated LLMs demonstrated good performance on dental examination questions and in executing tasks. DeepSeek-R1 consistently outperformed the others. While LLMs showed potential as supportive tools in dental education, further refinement and validation are needed before formal adoption in graduate medical educational and clinical training settings.

Abstract Background: Respiratory failure (RF) and atrial fibrillation/flutter (AF/AFL) often occur together in older adults, but long-term national mortality trends for the two conditions combined have not been described. We examined trends and disparities in deaths with co-listed RF and AF/AFL among U.S. adults aged 65 years and older from 1999 to 2024, and projected rates through 2035. Methodology: We used the CDC WONDER Multiple Cause of Death database to identify deaths with ICD 10 codes J96 (RF) and I48 (AF/AFL) listed together. Age-adjusted mortality rates (AAMRs) per 100,000 were standardized to the 2000 U.S. population and stratified by sex, race/ethnicity, census region, urbanization, state, and place of death. Joinpoint regression was used to estimate annual percent changes (APCs) and average annual percent changes (AAPCs). Forecasts for 2025 to 2035 were generated with an exponential smoothing (ETS) model. Results: A total of 433,598 deaths were recorded. The overall AAMR rose from 12.8 in 1999 to 66.7 in 2024 (AAPC 8.11%; 95% CI, 7.35 to 8.87; P < 0.0001). Three segments were identified: an increase from 1999 to 2018 (APC 7.73%), a sharp rise from 2018 to 2021 (APC 18.10%), and a decline from 2021 to 2024 (APC -5.25%). Males had a higher AAMR and a steeper increase than females (AAPC 8.44% vs 7.81%). Non-Hispanic White adults had the highest mean AAMR, Hispanic adults had the largest relative increase (AAPC 8.72%), and Non-Hispanic Asian/Pacific Islander adults had the smallest (AAPC 6.23%). The Midwest had the fastest regional growth (AAPC 9.35%). From 1999 to 2020, non-metropolitan areas increased faster than metropolitan areas (AAPC 10.09% vs 8.21%). State AAMRs ranged from 24.7 in Ohio to 85.1 in Louisiana. Most deaths occurred in hospital inpatient settings (64.1%), followed by nursing homes (14.1%) and the home (11.9%). The model projects an AAMR of 122.96 per 100,000 by 2035 (95% prediction interval, 85.42 to 160.50). Conclusions: Mortality involving RF with AF/AFL among older U.S. adults increased more than fivefold over 25 years, with a marked surge during the COVID 19 period and only a partial decline afterward. Differences by sex, race/ethnicity, region, and urbanization point to groups that may benefit from earlier detection and coordinated cardiopulmonary care.

Background Implantable loop recorders (ILRs) provide continuous rhythm monitoring. Professional society guidelines and expert consensus statements recommend ILR use for patients with recurrent syncope and cryptogenic stroke, but recommendations are weaker for other indications. We assessed ILR use over time and concordance between indication and clinical guidance. Methods We conducted a retrospective cohort study using Epic Cosmos data from 1/1/2020-12/31/2025. Among active patients with at least one of 13 diagnoses potentially eligible for ILR placement, we identified ILR placements and classified them by concordance with professional society guidance: concordant, possibly, or non-addressed. Annual incidence was estimated overall and by indication. We also described the proportion of patients who received longer-term (>7 days) rhythm monitoring in the year prior to placement. Results Of 47,046,706 patients with diagnoses potentially eligible for ILR placement, 201,103 (0.4%) had an ILR placed. ILR placements increased from 3.08 ILRs per 100,000 patient-days in 2020 to 4.13 in 2025 (5.9% annual growth). The most common indications were cryptogenic stroke (28.6%) and atrial fibrillation without prior ablation (21.4%). Overall, 43.9% were guidance concordant, 28.5% possibly concordant, and 24.8% non-addressed. Relative annual growth in ILR placements per 100,000 patient-days was significant across all guidance categories: concordant (1.3%, 95% CI, 0.9%-1.7%), possibly concordant (5.5%, 95% CI, 5.0%-6.0%) and non-addressed (7.4%, 95% CI, 6.8%-8.0%). Among 125,631 outpatient placements, 50,181 (39.9%) had any prior long-term rhythm monitoring. Conclusion ILR placements are uncommon but increasing, with faster annual growth for indications that may not be guidance concordant. More than half of patients lacked long-term rhythm monitoring prior to outpatient ILR placement.

BACKGROUND: Because of the high mortality rate associated with fulminant myocarditis (FM), there is limited evidence regarding the prognostic efficacy of endomyocardial biopsy (EMB). In this study, we aimed to evaluate the influence of EMB in the early phase after admission on treatment and prognosis in FM using a large-scale nationwide registry in Japan. METHODS: Patients with FM who required catecholamine or mechanical circulatory support between 2012 and 2017 from 235 hospitals across Japan were included. The primary outcome of death or heart transplantation within 90 days according to performance of early EMB were determined using Kaplan-Meier and Cox regression analyses. Factors associated with performance of early EMB, and subsequent medical treatment were analyzed. RESULTS: The median age of 736 patients with clinical FM was 56 years, and 407 patients (55%) received EMB. Most EMB (89%) were performed during the early phase (within 5 days of admission) and 63% were performed on the first day of admission. The prognosis of FM patients who underwent EMB was more favorable than that of those who did not based on the landmark analysis (log-rank test, P=0.04). Factor analysis demonstrated that FM patients who underwent EMB had a lower left ventricular ejection fraction, higher incidence of cardiogenic shock on admission, and higher rate of early mechanical circulatory support, as well as early initiation of corticosteroids and guideline-directed medical therapy (GDMT) for heart failure. Absence of any GDMT was associated with a less favorable prognosis on multivariate analysis (hazard ratio, 4.34 [95% CI, 3.14?6.01]; P<0.0001). CONCLUSIONS: Although performing EMB in the early phase after admission depends on disease severity in FM patients, it is associated with early initiation of advanced medical treatment and may contribute to improving the prognosis.

Abstract Background The SYNTAX score (SS) quantifies the severity and complexity of coronary artery lesions and serves as an independent predictor of major adverse cardiovascular events and mortality in patients with acute coronary syndrome (ACS). However, few studies have examined the association between SS and in-hospital cardiac arrest (IHCA) in this population. Therefore, this study aims to elucidate the relationship between SS and the incidence of IHCA in patients with ACS. Methods This study consecutively enrolled 3,224 patients undergoing percutaneous coronary intervention (PCI). Logistic regression and restricted cubic spline (RCS) analyses were employed to examine the association between SS and the incidence of IHCA. Participants were stratified into three groups based on SS: Group T1 (SS ? 10, N = 1,097), Group T2 (10 < SS ? 18, N = 1,089), and Group T3 (SS > 18, N = 1,038). The primary endpoint was the incidence of IHCA. Results The overall incidence of IHCA was 4% (N=147). After adjusting for covariates, SS was significantly associated with the incidence of IHCA in ACS patients treated with PCI (OR = 1.0400; 95% confidence interval (CI) = 1.0200?1.0700; p < 0.001). Compared with the T1 group, the T3 group exhibited an increased risk of IHCA (OR = 2.1800; 95% CI = 1.2900?3.6900; p = 0.0040). Subgroup analyses revealed that, after covariate adjustment, patients with ST-segment elevation myocardial infarction (STEMI) had an increased risk of IHCA (OR = 1.0700; 95% CI = 1.0300?1.1100; p < 0.001). Similarly, both patients with diabetes mellitus (DM) (OR = 1.0400; 95% CI = 1.000?1.0700; p = 0.0270) and those without DM (OR = 1.0600; 95% CI = 1.0200?1.1000; p = 0.0020) showed an increased risk. Furthermore, elderly patients (?60 years) (OR = 1.0300; 95% CI = 1.0100?1.0700; p = 0.0210) and non-elderly patients (<60 years) (OR = 1.0500; 95% CI = 1.000?1.1000; p = 0.0470) had an increased risk, as did male patients (OR = 1.0500; 95% CI = 1.0200?1.0700; p = 0.0020). RCS analysis indicated a dose-response relationship between IHCA incidence and SS (nonlinear p-value = 0.906), with the risk of IHCA increasing when SS exceeded 23.975. Incorporating SS into the baseline risk model improved the predictive value for IHCA incidence in ACS patients undergoing PCI (Net reclassification improvement [NRI]: 0.3537 [0.1906?0.5167], p < 0.001; Integrated discriminant improvement [IDI]: 0.0104 [0.0025?0.0183], p = 0.0097). Conclusions Among patients with ACS undergoing PCI, SS is significantly associated with the incidence of IHCA. Consequently, SS may serve as an effective predictor of IHCA in this population.

Background. Regulatory pressure to avoid confusingly similar drug names appears to have pushed manufacturers to coin more distinctive proprietary names, but no one has quantitatively analyzed this trend. Objective. To determine whether proprietary drug names became more orthographically distinctive (unusual in spelling) over time. Methods. We examined 1,321 US Food and Drug Administration (FDA) new molecular entity (NME) names (1985-2024), 2,769 FDA Orange Book trade names (1982-2026), 177,337 US pharmaceutical trademarks (1980-2026), and 1,273 generic names (1982-2025). Compared to prior names (including those already marketed) and ordinary English, we scored each name's character trigram (three-letter sequence) surprisal (statistical unexpectedness) and its edit-distance similarity to the closest existing names. Linear regression tested time trends, controlling for name length. Results. Mean NME trigram surprisal rose in every decade between the 1980s and 2020s, from 7.21 to 8.50 nats (natural-logarithm units, higher meaning less predictable), an 18% increase (b = 0.038, p < .001, R2 = 0.34). Half of 2020s names (7% in the 1980s) contained a letter sequence found in no common English word (e.g., Jesduvroq, Omvoh). Nearest-neighbor similarity fell after the early 1990s. Trademark data showed the same trend (b = 0.016, p < .001). Generic names showed a weaker trend (b = 0.011, R2 = 0.063). Conclusions. Over four decades, drug names became more orthographically distinctive, consistent with namespace crowding, deliberate efforts to avoid confusing names, and branding strategy. Because unfamiliar letter sequences can introduce other error pathways, increased distinctiveness does not necessarily imply improved safety.

BackgroundFospropofol disodium is a water-soluble prodrug of propofol that avoids a lipid emulsion carrier. It may therefore reduce injection pain, cardiorespiratory depression and lipid exposure. In May 2021 it was approved in China (H20210017) for induction of general anaesthesia in adults. Randomised trials have since tested it for sedation outside the operating room, but this setting has not been systematically reviewed. MethodsWe followed PRISMA 2020 and PRISMA-S and searched Europe PMC, PubMed, Embase, Cochrane CENTRAL, Web of Science and the Chinese databases CNKI, Wanfang and VIP (the last accessed through the XJMU Library database proxy) from inception to 2026. Eligible patients were adults receiving sedation for purposes other than general anaesthesia induction or maintenance, including continuous sedation during ICU mechanical ventilation and procedural sedation. These uses are referred to here as sedation outside the operating room. We included randomised controlled trials with propofol as the comparator and excluded trials of general anaesthesia induction or maintenance to avoid overlap with the published induction meta-analysis. Binary outcomes were pooled with a DerSimonian-Laird random-effects model, and REML plus modified Hartung-Knapp estimates were reported alongside to improve interval coverage when few studies were available. Outcomes with a high proportion of zero cells were also analysed with the Peto method. We stratified by setting and blinding and performed leave-one-out analysis, trial sequential analysis (TSA) and GRADE assessment. Hypotension reached the prespecified threshold of at least 10 studies, so publication bias was assessed with the Harbord test, with the originally specified Eggers test reported alongside. The protocol was prospectively registered and took effect on 16 September 2026. All searches were completed on 21 September 2026, and screening, extraction and analysis were performed after registration. ResultsTwelve randomised controlled trials were included. Event counts for all 12 studies were checked against the full-text original publications. For Liu 2026, a preprint, counts were taken directly from its Tables 2 and 3. Compared with propofol, fospropofol disodium reduced injection pain under the DerSimonian-Laird model (8 studies, OR 0.09, 0.03-0.21) and increased pruritus/paraesthesia (4 studies, OR 32.56, 12.89-82.26; RD +28.5%). During procedural sedation, it was associated with fewer respiratory adverse events (5 studies, OR 0.19, 0.11-0.32). This composite includes respiratory depression, hypoxaemia and related events reported by individual trials and should not be extrapolated to all adult sedation settings. For hypertriglyceridaemia, the DerSimonian-Laird estimate was OR 0.29 (0.13-0.65), but all four studies were conducted in ICU settings and the REML plus modified Hartung-Knapp estimate was 0.29 (0.08-1.08), with a confidence interval crossing 1. Certainty was very low, so this finding remains hypothesisgenerating. Hypotension differed by setting: OR 0.24 (0.13-0.42) for procedural sedation and 0.90 (0.53-1.55) for continuous ICU sedation, with a significant interaction (P < 0.001). The overall estimate (OR 0.51, 0.28-0.93) is reported for summary only. Under REML plus modified HartungKnapp it was 0.51 (0.25-1.03), crossing 1, so it does not support a claim that the drug lowers blood pressure and should not be extrapolated to the ICU. Bradycardia did not differ significantly (9 studies, OR 0.45, 0.17-1.18), and the direction reversed in the only double-blind study. Two studies reported slower onset or loss of consciousness with fospropofol disodium (MD +2.22 and +0.92 min), but these were not pooled because heterogeneity was extreme (I2 = 99.6%). Recovery, discharge and successful extubation showed no clear differences, although heterogeneity was high (I2 = 85%-92%) and the evidence cannot establish equivalence. Sedation efficacy was not pooled because definitions differed. Patient-important outcomes (death, delirium, ICU length of stay and duration of mechanical ventilation) were each reported by only one or two small studies with inconsistent definitions and time points, so no reliable conclusion can be drawn. Setting-specific results should take priority over the overall mean. Certainty ranged from very low to moderate. O_TBL View this table: org.highwire.dtl.DTLVardef@174a615org.highwire.dtl.DTLVardef@143c610org.highwire.dtl.DTLVardef@807653org.highwire.dtl.DTLVardef@1d857eborg.highwire.dtl.DTLVardef@740a59_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 2:C_FLOATNO O_TABLECAPTIONBinary event counts by study and outcome (fospropofol disodium versus propofol). C_TABLECAPTION C_TBL O_TBL View this table: org.highwire.dtl.DTLVardef@538773org.highwire.dtl.DTLVardef@1e1ccbcorg.highwire.dtl.DTLVardef@1486540org.highwire.dtl.DTLVardef@1ef63f9org.highwire.dtl.DTLVardef@18ca7cb_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 3:C_FLOATNO O_TABLECAPTIONThreshold, recording window and intervention requirement for hypotension in each study (10 studies). C_TABLECAPTION C_TBL ConclusionsDuring procedural sedation, fospropofol disodium may reduce injection pain and respiratory adverse events and may lower the risk of hypotension compared with propofol. This hypotension benefit should not be extrapolated to the ICU. During continuous ICU sedation no data were available for injection pain or respiratory adverse events, so the safety evidence in that setting remains limited. Hypertriglyceridaemia was lower only under the DerSimonian-Laird model. Because the result depends on the method and certainty is very low, it cannot be treated as definitive. The main cost is a clear increase in pruritus and abnormal sensations. Onset may be slower, but the evidence comes from two bolus-dosing studies in procedural sedation, and no such disadvantage was seen during continuous ICU infusion. Evidence on sedation efficacy, recovery time, discharge time and successful extubation is limited, and equivalence between the two drugs cannot be asserted. Because most studies were small and open-label and certainty ranged from very low to moderate, these findings support investigational use only and do not justify a routine clinical recommendation. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Europe PMC, PubMed, Embase, Cochrane CENTRAL, Web of Science Core Collection and Chinese databases (CNKI, Wanfang, VIP) by crossing drug terms (fospropofol, fospropofol disodium, Lusedra, Aquavan) with sedation setting terms (ICU, mechanical ventilation, endoscopy, gastroscopy, hysteroscopy, bronchoscopy, procedural sedation). Within the retrieved literature, the only relevant meta-analysis addressed general anaesthesia induction; no synthesis of the sedation setting was identified. Added value of this studyThe present synthesis focuses on sedation outside the operating room, includes 12 RCTs, and stratifies by setting. It reports eight safety and efficacy outcomes (recovery time and other continuous outcomes are reported narratively), together with heterogeneity, leave-one-out sensitivity analysis, trial sequential analysis and GRADE certainty, and it quantifies the costs of fospropofol disodium (pruritus/paraesthesia; slower onset after bolus dosing). Clinical implicationsFospropofol disodium may reduce injection pain during sedation. For hypertriglyceridaemia the result depends on the estimator and certainty is very low. During procedural sedation it may reduce hypotension and respiratory adverse events, whereas the evidence for a hypotension benefit during continuous ICU sedation is weak. Because the approved indication in China is adult general anaesthesia induction only, these uses remain investigational; they do not constitute a routine clinical recommendation. Applicability to specific patient groups remains an inference from pharmacological mechanism.

Background: Robot-assisted radical prostatectomy is the standard minimally invasive treatment for localized prostate cancer. Conventional multiport robotic surgery is widely applied yet associated with more abdominal trauma and postoperative discomfort. Single-port robotic surgery can further minimize surgical injury. The domestic KangDuo robotic system has been gradually used in urological oncology, but high-level prospective evidence comparing single-port and multiport extraperitoneal radical prostatectomy remains scarce. This trial aims to compare the efficacy and safety of these two surgical approaches. Methods: This is a single-center, prospective, 1:1 randomized, non-inferiority trial. Eligible patients diagnosed with cT1c-cT2cN0M0 localized prostate cancer will be randomized to receive either single-port (experimental group) or multiport (control group) extraperitoneal robotic radical prostatectomy using the KangDuo system. All participants will receive standardized enhanced recovery after surgery (ERAS) protocols. The primary endpoint is postoperative positive surgical margin rate. Perioperative parameters, postoperative recovery, medium-term functional recovery and oncological outcomes will be assessed comprehensively. Expected results: We hypothesize that the single-port approach is non-inferior to the multiport approach in terms of oncological radical effect. The single-port technique is expected to provide better minimally invasive benefits, with comparable perioperative safety, urinary/sexual function recovery and mid-term oncological outcomes between groups. Conclusions: This randomized trial will provide high-quality clinical evidence for the application of domestic single-port robotic surgery. The findings will facilitate individualized surgical selection for patients with localized prostate cancer. Trial Registration: Chinese Clinical Trial Registry, ChiCTR2600125669 (http://www.chictr.org.cn/showproj.aspx?proj=2600125669).

Introduction: Fighting the ventilator (FV) is characterized by a patients active counteraction of respiratory gas flow across multiple breaths during mechanical ventilation. An effective ventilation is prevented during such episodes. The objective of this exploratory study was to evaluate clinicians knowledge, perception and agreement regarding this condition. Methods: In a cross-sectional online survey, medical professionals with experience in intensive care medicine (mostly neonatal and pediatric patients) responded to 11 questions covering various clinical aspects of FV. Results: All respondents were familiar with the phenomenon and assessed it to be clinically relevant. Neonates were perceived to be predominantly affected. Promoting factors of FV included inadequate sedation and ventilation-associated factors. In clinical practice, the participants identified FV by clinical evaluation, analysis of ventilator waveforms and capnography and used both pharmacological and non-pharmacological intervention strategies. There was no consensus concerning the English terminology of the condition. Only few respondents were familiar with local guidelines to manage FV. Conclusion: Although there was consensus on the relevance of FV, diagnostics and management strategies were highly heterogeneous. Many participants agreed that poor patient-ventilator synchrony was an important cause of FV. Future work should focus on characterizing and generating evidence on FV.

Objective Based on the bioinformatics method of multi-database integration, this study systematically analyzes the expression characteristics, clinical pathological correlation, prognostic value, potential molecular mechanisms, and immune infiltration patterns of hepatocyte growth factor receptor (MET) in gastric cancer. Methods The UALCAN and GEPIA databases were employed to examine the differential expression of MET between gastric cancer and normal gastric mucosal tissues, as well as its associations with clinicopathological features. Kaplan-Meier Plotter was utilized to evaluate the impact of MET expression on overall survival (OS) and progression-free survival (PFS). Protein-protein interaction (PPI) network was constructed via LinkedOmics, followed by Gene Ontology (GO) functional annotation and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis of co-expressed genes. Four algorithms, TIMER, CIBERSORT, EPIC, and MCPcounter, were used to cross evaluate the correlation between MET expression and immune cell infiltration; Further validate the cell type specific expression of MET using the gastric cancer single-cell sequencing queues (GSE134520, GSE167297) built into the TISCH database. Results MET expression was significantly elevated in gastric cancer tissues compared with normal gastric mucosa (P < .05), and its expression level was significantly correlated with tumor grade and TNM stage. Patients with high MET expression exhibited significantly poorer OS and PFS than those with low MET expression (P < .05). The PPI network revealed that MET could interact with 20 key proteins, including EGFR, ERBB2, HGF, STAT3, and GRB2 etc. GO enrichment analysis suggests that differentially expressed genes are significantly enriched in functions such as the ERBB signaling pathway, cadherin binding, and DNA repair complexes; KEGG enrichment analysis showed that MET related genes were significantly enriched in pathways such as homologous recombination, nuclear cytoplasmic transport, mismatch repair, and oxidative phosphorylation. Immune infiltration analysis showed that the negative association between MET and B cells infiltration has cross algorithm robustness, while the association with neutrophils, CD8+ T cells, CD4+ T cells, and macrophages exhibits algorithmic heterogeneity or insignificance; There is no significant correlation between MET and common immune checkpoint molecules such as PD-1, PD-L1, CTLA4, etc. Single cell validation further confirmed that MET is mainly enriched in malignant epithelial cells and endothelial cells, and is almost not expressed in immune cells. Conclusions Multidimensional bioinformatic analyses demonstrate that elevated MET expression serves as an independent risk factor for unfavorable prognosis in gastric cancer. MET may mediate dual drug resistance in gastric cancer via crosstalk with multiple signaling molecules (including EGFR, ERBB2, HGF, STAT3 and GRB2) and dysregulation of the homologous recombination repair pathway. Results from multiple-algorithm immune infiltration analysis, single-cell dataset analysis and immune checkpoint correlation analysis indicate that MET exerts only modest direct regulatory effects on the gastric cancer immune microenvironment. This exploratory study offers systematic bioinformatic evidence supporting MET as a candidate prognostic biomarker and potential therapeutic target for gastric cancer. Further functional experiments and prospective cohort studies are required to validate its molecular mechanisms and clinical utility.

Objective To evaluate the information quality, reliability, readability, and content deficits of ChatGPT, DeepSeek, and Doubao in answering frequently asked questions about bee stings. Methods Twenty-five high-frequency patient questions were selected based on Google Trends, domestic health platforms, and allergy guidelines, and submitted to the three LLMs, yielding 75 responses. Two emergency physicians independently assessed quality using GQS, mDISCERN, QAMAI, EQIP, and PEMAT-U/A. Readability was evaluated using six indices (ARI, FRES, GFI, FKGL, CLI, SMOG). Content deficits were classified qualitatively. Twenty emergency department patients evaluated the comprehensibility and credibility of AI responses. Results Significant differences were found among the three models on all quality metrics (all P < 0.01). DeepSeek achieved the highest mDISCERN score (median 21.00); ChatGPT led on QAMAI (25.00) and EQIP (75.00%); Doubao ranked lowest on all quality indicators but highest on PEMAT-U (73.00%). No model met the sixth-grade reading level standard. Eleven content deficits were identified: outdated medical advice (45.45%), omissions (36.36%), and hallucinations (18.18%). Doubao received the highest patient preference (45.0%). Conclusion The three LLMs exhibited distinct strengths: DeepSeek in source reliability, ChatGPT in overall quality, and Doubao in understandability. All models had excessively high readability levels, and outdated medical advice was the predominant content deficit. Objective To evaluate the information quality, reliability, readability, and content deficits of ChatGPT, DeepSeek, and Doubao in answering frequently asked questions about bee stings. Methods Twenty-five high-frequency patient questions were selected based on Google Trends, domestic health platforms, and allergy guidelines, and submitted to the three LLMs, yielding 75 responses. Two emergency physicians independently assessed quality using GQS, mDISCERN, QAMAI, EQIP, and PEMAT-U/A. Readability was evaluated using six indices (ARI, FRES, GFI, FKGL, CLI, SMOG). Content deficits were classified qualitatively. Twenty emergency department patients evaluated the comprehensibility and credibility of AI responses. Results Significant differences were found among the three models on all quality metrics (all P < 0.01). DeepSeek achieved the highest mDISCERN score (median 21.00); ChatGPT led on QAMAI (25.00) and EQIP (75.00%); Doubao ranked lowest on all quality indicators but highest on PEMAT-U (73.00%). No model met the sixth-grade reading level standard. Eleven content deficits were identified: outdated medical advice (45.45%), omissions (36.36%), and hallucinations (18.18%). Doubao received the highest patient preference (45.0%). Conclusion The three LLMs exhibited distinct strengths: DeepSeek in source reliability, ChatGPT in overall quality, and Doubao in understandability. All models had excessively high readability levels, and outdated medical advice was the predominant content deficit.

HIV infection significantly elevated the odds of cardiovascular diseases, including myocardial fibrosis. We aimed to determine the difference of late gadolinium enhancement (LGE), extracellular volume (ECV), T1, and T2 using cardiac magnetic resonance imaging (CMR) in patients living with HIV (PLWH) and healthy controls. The databases Scopus, Web of Science, Embase, and PubMed were searched systematically using relevant keywords. STATA version 17 was used for meta-analysis using random effect and fixed effect models for heterogeneous and non-heterogeneous analyses. An overall number of 13 studies were included in the current analysis involving 1425 PLWH and 766 healthy controls. PLWH showed significantly higher LGE (OR: 5.47, 95% CI: 1.90-15.64, p<0.001) and ECV (mean difference: 1.46, 95% CI: 0.21-2.71, p=0.02) compared to controls. However, differences in Left Ventricular Ejection Fraction (LVEF) were not significant (mean difference: -1.41, 95% CI: -2.81- -0.01, p=0.05). There were no meaningful disparities in pro B-type natriuretic peptide (BNP) values (mean difference: 8.67, 95% CI: 0.04-17.29, p=0.05) or T2 values (mean difference: 0.91 ms, 95% CI: -1.04-2.86, p=0.36), but T1 values were significantly higher in PLWH (mean difference: 13.78 ms, 95% CI: 9.16-18.40, p<0.001). In meta regression, LGE was correlated with nadir CD4 (z=-3.41, p-value<0.001). In addition, ECV was correlated with white race (Z=-3.97, p-value<0.001), Hepatitis C (Z=-2.08, p-value=0.037), and smoking (Z=2.05, p-value=0.041). HIV is related to a significantly elevated rate of myocardial fibrosis, and factors such as lower nadir CD4, white race, hepatitis C, and smoking were correlated with hepatitis C. Keywords: Myocardial fibrosis, HIV, AIDS, Cardiovascular diseases, Heart failure

Abstract Objectives To conduct a Delphi process to inform an international, consensus definition of manuscript peer review. Design Three-round Delphi consensus study including two surveys and one virtual consensus meeting. Peer review features identified through a prior scoping review were rated on a 5-point Likert scale in Rounds 1 and 2 and voted on using include, exclude, and abstain options in Round 3. Consensus was defined as [&ge;]80% agreement. Setting International experts representing interest holders affected by manuscript peer review across the fields of biomedical, health, and social sciences, economics, and healthcare-related industries. Participants Round 1 participants were purposively recruited via email from corresponding authors of articles included in the preceding scoping review. Round 2 participants were those who completed Round 1. Round 3 participants were purposely selected to address gaps in representation from earlier rounds, with attention to diversity of perspectives and equity-relevant characteristics informed by PROGRESS-Plus (e.g., geographic location, gender, race/ethnicity, occupation, and socioeconomic context). Participants were required to communicate in English. Main outcome measures Consensus on the terminology, scope, characteristics, functions, processes, and reviewer characteristics that should inform a definition of manuscript peer review. Results Across the three rounds (N=143, 109, and 16 participants, respectively), 44 peer review features across six domains (Characteristics, Function, Motivation, Assessment, Process, and Challenges) and six peer reviewer characteristics met the consensus threshold for inclusion. Consensus was also reached on terminology to describe manuscript peer review and the peer review workflow. Results were synthesized into a final conceptualization of manuscript peer review, consisting of one definition and eight pillars.The consensus definition is: Manuscript peer review is a structured process by which human reviewers assess scholarly manuscripts, with the aim of improving the quality and trustworthiness of published research in line with norms of reciprocity to the research community. The eight pillars characterize manuscript peer review and are as follows: Principled, Constructive, Timely, Transparent, Professional, Quality, Confidential, and Pluralistic. Conclusions This three-round international Delphi established a consensus-based, normative conceptualization of manuscript peer review as a distinct, human-led process to improve the quality and trustworthiness of scholarly research. The resulting definition and eight pillars may provide a shared foundation for research, evaluation, education, and improvement across publishing contexts while allowing operational features to remain adaptable.