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We evaluate a single center’s, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). Patients undergoing keloid treatment were identified (2008–2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1–53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6–30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group. MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes. •The majority of medically managed patients experienced at least some improvement in symptomatology and cosmesis.•Surgical excision and surgical excision with radiotherapy had similar recurrence rates.•Higher radiation doses were associated with decreased recurrence.•Postoperative steroids (OR 9.5) and male sex (OR 3.3) were associated with increased recurrence.•Keloid locations on an extremity (OR 19.5) and larger surface area (OR 1.0) were associated with increased complications.

Background The incidence of obesity is on the rise around the globe. Outside of the massive weight loss (MWL) patient population, knowledge of risk factors associated with abdominal body contouring (BC) is limited. This systematic review and meta-analysis assesses the impact of obesity has on cosmetic abdominal BC outcomes. Methods A systematic review conducted in accordance with PRISMA 2020 was done. PubMed, Embase, Scopus, and COCHRANE databases were reviewed under search syntax “obesity,” “abdominoplasty,” “panniculectomy,” and “body contouring” for articles. Cosmetic was defined as abdominoplasty or panniculectomy outside the context of MWL. Obesity was defined as BMI ≥ 30 kg/m 2 . Studies reporting postoperative outcomes with less than 50% of their population involving MWL patients were included. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Results Of 3088 initial studies, 16 met inclusion criteria, and nine were used for pooled and meta-analysis. Meta-analysis demonstrated that obesity was associated with more seromas (OR 1.45, 1.06–1.98, p  = 0.02), hematomas (OR 2.21, 1.07–4.57, p  = 0.03), and total surgical site occurrences (OR 1.99, 1.30–3.04, p  = 0.0016). There was no significant difference in odds of any other complications. Analysis by obesity class showed no significant increase in odds in seromas or wound dehiscence. Conclusions This review demonstrates obesity increased odds of postoperative complications following cosmetic abdominal BC. However, risk of complications does not continue to increase with higher obesity class. A BMI ≥ 30 kg/m 2 should not be a strict contraindication to cosmetic abdominal BC. Instead, plastic surgeons should evaluate patients on a case-by-case basis. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Tranexamic acid (TXA), a fibrinolysis inhibitor, is widely used in various surgical fields to minimize blood loss. However, its efficacy and safety in plastic surgery, especially in reduction mammaplasty and abdominoplasty, remain underexplored. This study investigates the utility of intravenous (IV) TXA in these procedures, focusing on reducing postoperative complications and evaluating its safety in the context of venous thromboembolism (VTE). Objectives To evaluate the efficacy and safety of TXA in reduction mammaplasty and abdominoplasty. Methods Using data from the TriNetX LLC (Cambridge, MA) National Health Research Network database, this retrospective study compared adult patients undergoing reduction mammaplasty or abdominoplasty who received intraoperative IV TXA against those who did not. Primary outcomes included postoperative seroma and hematoma incidences, whereas secondary outcomes assessed the necessity for procedural drainage and the occurrence of VTE within 1-year postsurgery. Results No significant differences in the rates or risks of hematoma, seroma, or the need for procedural drainage between patients administered IV TXA and those who were not, for both reduction mammaplasty and abdominoplasty. Additionally, IV TXA did not increase the risk of VTE in either patient group. Conclusions IV TXA application in reduction mammaplasty and abdominoplasty does not provide added benefits in reducing postoperative complications such as seroma, hematoma, or the necessity for procedural drainage. Furthermore, it does not alter the risk of thromboembolic events. These findings highlight the need for further research, particularly through randomized control trials, to understand TXA's efficacy in plastic surgery. Level of Evidence: 3 (Therapeutic)

Comprehensively mapping the genetic basis of human disease across diverse individuals is a long-standing goal for the field of human genetics 1 – 4 . The All of Us Research Program is a longitudinal cohort study aiming to enrol a diverse group of at least one million individuals across the USA to accelerate biomedical research and improve human health 5 , 6 . Here we describe the programme’s genomics data release of 245,388 clinical-grade genome sequences. This resource is unique in its diversity as 77% of participants are from communities that are historically under-represented in biomedical research and 46% are individuals from under-represented racial and ethnic minorities. All of Us identified more than 1 billion genetic variants, including more than 275 million previously unreported genetic variants, more than 3.9 million of which had coding consequences. Leveraging linkage between genomic data and the longitudinal electronic health record, we evaluated 3,724 genetic variants associated with 117 diseases and found high replication rates across both participants of European ancestry and participants of African ancestry. Summary-level data are publicly available, and individual-level data can be accessed by researchers through the All of Us Researcher Workbench using a unique data passport model with a median time from initial researcher registration to data access of 29 hours. We anticipate that this diverse dataset will advance the promise of genomic medicine for all. A study describes the release of clinical-grade whole-genome sequence data for 245,388 diverse participants by the All of Us Research Program and characterizes the properties of the dataset.

Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18–30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55–77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI –0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. Australian Government Medical Research Future Fund.

Delirium is a severe and common complication following transcatheter aortic valve implantation (TAVI). We sought to identify the prevalence and risk factors associated with the development of postprocedural delirium in patients aged over 60 years who underwent elective TAVI for aortic stenosis. Overall, 1,051 articles were searched, from which 9 studies were included. The prevalence of delirium following TAVI was higher in studies that assessed delirium for a minimum of 3 consecutive days (24.9%) compared with the studies that did not (2%). There were large effect sizes (d > 0.8) for 3 risk factors: acute kidney injury (odds ratio [OR] 5, p < 0.001), transapical approach (OR 4, p < 0.001) and carotid artery disease (OR 4, p < 0.001), whilst small effect sizes were found for a history of atrial fibrillation, prior stroke/transient ischemic attack, peripheral artery disease, hypertension, and prior cognitive impairment. In conclusion, 23% of patients 60 years and over who underwent TAVI experience delirium, a preventative cause of cognitive impairment and dementia. Recognition of risk factors for delirium after TAVI, such as a history of carotid artery disease, development of acute kidney injury, or use of a transapical approach, provides an opportunity to implement proven delirium preventative measures.

Mounted on the sides of two widely separated spacecraft, the two Heliospheric Imager (HI) instruments onboard NASA’s STEREO mission view, for the first time, the space between the Sun and Earth. These instruments are wide-angle visible-light imagers that incorporate sufficient baffling to eliminate scattered light to the extent that the passage of solar coronal mass ejections (CMEs) through the heliosphere can be detected. Each HI instrument comprises two cameras, HI-1 and HI-2, which have 20° and 70° fields of view and are off-pointed from the Sun direction by 14.0° and 53.7°, respectively, with their optical axes aligned in the ecliptic plane. This arrangement provides coverage over solar elongation angles from 4.0° to 88.7° at the viewpoints of the two spacecraft, thereby allowing the observation of Earth-directed CMEs along the Sun – Earth line to the vicinity of the Earth and beyond. Given the two separated platforms, this also presents the first opportunity to view the structure and evolution of CMEs in three dimensions. The STEREO spacecraft were launched from Cape Canaveral Air Force Base in late October 2006, and the HI instruments have been performing scientific observations since early 2007. The design, development, manufacture, and calibration of these unique instruments are reviewed in this paper. Mission operations, including the initial commissioning phase and the science operations phase, are described. Data processing and analysis procedures are briefly discussed, and ground-test results and in-orbit observations are used to demonstrate that the performance of the instruments meets the original scientific requirements.

By exploiting data from the STEREO/heliospheric imagers (HI) we extend a well‐established technique developed for coronal analysis by producing time‐elongation plots that reveal the nature of solar transient activity over a far more extensive region of the heliosphere than previously possible from coronagraph images. Despite the simplicity of these plots, their power in demonstrating how the plethora of ascending coronal features observed near the Sun evolve as they move antisunward is obvious. The time‐elongation profile of a transient tracked by HI can, moreover, be used to establish its angle out of the plane‐of‐the‐sky; an illustration of such analysis reveals coronal mass ejection material that can be clearly observed propagating out to distances beyond 1AU. This work confirms the value of the time‐elongation format in identifying/characterising transient activity in the inner heliosphere, whilst also validating the ability of HI to continuously monitor solar ejecta out to and beyond 1AU.

Objectives. To examine national trends in the use of various pharmacological pain medication classes by race/ethnicity among the US pain population. Methods. We used data from the Medical Expenditure Panel Survey to conduct a nationally representative, serial cross-sectional study of the noninstitutionalized US adult population from 2000 to 2015. We identified adults with moderate or severe self-reported pain and excluded individuals with cancer. We used complex survey design to provide national estimates of the percentage of adults with noncancer pain who received prescription pain medications among 4 groups: non-Hispanic White, non-Hispanic Black, Hispanic or Latino, and other. Results. The age- and gender-adjusted percentage of prescription opioid use increased across all groups, with the greatest increase among non-Hispanic White individuals. By 2015, the percentage of non-Hispanic Black adults using opioids approximated that of non-Hispanic White adults—in 2015, approximately 23% of adults in these 2 groups used opioids. Conclusions. To our knowledge, this is the first evidence of a narrowing divide in opioid prescribing by race. However, in the context of the national epidemic of opioid-related addiction and mortality, opioid-related risks do not appear commensurate with the purported benefits.

The long and the short of it The tidy classification system that divided γ-ray bursts (GRBs) into long-duration busts (lasting more than two seconds) and short may have had its day. The final nail in its coffin may be GRB 060614. Discovered on 14 June 2006 by the Burst Alert Telescope on-board the Swift satellite, this burst was long, at 102 seconds, but as reported in a clutch of papers in this issue, it has a number of properties, including the absence of an accompanying supernova, that were previously considered diagnostic of a 'short' GRB. The hunt is now on for a classification system to take account of the diversity now apparent in GRBs. In the accompanying News & Views, Bing Zhang suggests that the answer may be to adopt a Type I/Type II classification similar to that used for supernovae. Optical observations of γ-ray burst (GRB) 060614 (duration ∼100s) rule out the presence of an associated supernova. This would seem to require a new explosive process: either a massive 'collapsar' that powers a GRB without any associated supernova, or a new type of engine, as long-lived as the collapsar but without a massive star. Over the past decade, our physical understanding of γ-ray bursts (GRBs) has progressed rapidly, thanks to the discovery and observation of their long-lived afterglow emission. Long-duration (≳2 s) GRBs are associated with the explosive deaths of massive stars (‘collapsars’, ref. 1 ), which produce accompanying supernovae 2 , 3 , 4 , 5 ; the short-duration (≲2 s) GRBs have a different origin, which has been argued to be the merger of two compact objects 6 , 7 , 8 , 9 . Here we report optical observations of GRB 060614 (duration ∼100 s, ref. 10 ) that rule out the presence of an associated supernova. This would seem to require a new explosive process: either a massive collapsar that powers a GRB without any associated supernova, or a new type of ‘engine’, as long-lived as the collapsar but without a massive star. We also show that the properties of the host galaxy (redshift z  = 0.125) distinguish it from other long-duration GRB hosts and suggest that an entirely new type of GRB progenitor may be required.