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Background Hemiarch replacement of the ascending aorta has become routine in many aortic centers. While the addition of coronary bypass does not add a lot of time to the procedure, it carries with more significant comorbidities. We hypothesize that the addition of CABG carries a higher risk of complication than hemiarch alone. Methods This is a single-center, retrospective cohort study of 419 patients undergoing elective hemiarch surgery between February 2010 and May 2023. Patients were categorized into concomitant CABG ( n  = 42) and non-CABG ( n  = 379) groups. Perioperative variables and outcomes were analyzed. Both univariate and multivariate logistic regressions were used to identify predictors for MACE. Results Of 419 patients, 42 (10%) patients received adjunctive CABG. This group was older (68.1 vs. 60.4 years, p  < 0.001) with more comorbidities associated with coronary artery disease (CAD), such as hypertension (92.9% vs. 59.2%, p  < 0.001), type 2 diabetes (33.3% vs. 8.8%, p  < 0.001), and atrial fibrillation (19% vs. 5.8%, p  = 0.006). CABG patients had longer cardiopulmonary bypass (158 vs. 131 min, p  < 0.001) and aortic cross-clamp (115.5 vs. 95 min, p  < 0.001) times and required more intraoperative blood products, FFP (4 vs. 2 units, p  = 0.010) and platelets (2 vs. 1 units, p  < 0.001). Postoperative complications, including arrhythmia (40.5% vs. 21.8%, p  = 0.012), mechanical circulatory support (11.9%, 1.9%, p  = 0.004), acute kidney injury (16.7% vs. 0.5%, p  < 0.001), infection (11.9% vs. 3.7%, p  = 0.032), mortality (9.5% vs. 0.5%, p  = 0.001), stroke (9.5% vs. 2.1%, p  = 0.024), and the composite outcome– MACE (21.4% vs. 2.9%, p  < 0.001) were higher in the CABG group. Multivariate analysis identified the number of bypassed vessels (OR: 2.23, CI 1.33–3.69, p  = 0.002), age (OR: 1.07, CI: 1.02–1.13, p  = 0.006), and female gender (OR: 3.53, CI: 1.31–9.64, p  = 0.012) as significant risk factors for MACE. Conclusions Concomitant CABG may increase the risk of MACE compared to other patients undergoing hemiarch. These data argue that the risk may be higher for concomitant CABG but should still undergo revascularization. Future research should focus on preoperative optimization, operative strategies, and sex-specific risk factors to improve elective hemiarch replacement outcomes.

Importance The number of patients with small nonfunctional pancreatic neuroendocrine tumors (NF-PanNETs) is increasing. However, the role of surgery for small NF-PanNETs remains unclear. Objective To evaluate the association between surgical resection for NF-PanNETs measuring 2 cm or smaller and survival. Design, Setting, and Participants This cohort study used data from the National Cancer Database and included patients with NF-pancreatic neuroendocrine neoplasms who were diagnosed between January 1, 2004, and December 31, 2017. Patients with small NF-PanNETs were divided into 2 groups: group 1a (tumor size, ≤1 cm) and group 1b (tumor size, 1.1-2.0 cm). Patients without information on tumor size, overall survival, and surgical resection were excluded. Data analysis was performed in June 2022. Exposures Patients with vs without surgical resection. Main Outcomes and Measures The primary outcome was overall survival of patients in group 1a or group 1b who underwent surgical resection compared with those who did not, which was evaluated using Kaplan-Meier estimates and multivariable Cox proportional hazards regression models. Interactions between preoperative factors and surgical resection were analyzed with a multivariable Cox proportional hazards regression model. Results Of the 10 504 patients with localized NF-PanNETs identified, 4641 were analyzed. These patients had a mean (SD) age of 60.5 (12.7) years and included 2338 males (50.4%). The median (IQR) follow-up time was 47.1 (28.2-71.6) months. In total, 1278 patients were in group 1a and 3363 patients were in group 1b. The surgical resection rates were 82.0% in group 1a and 87.0% in group 1b. After adjustment for preoperative factors, surgical resection was associated with longer survival for patients in group 1b (hazard ratio [HR], 0.58; 95% CI, 0.42-0.80;P < .001) but not for patients in group 1a (HR, 0.68; 95% CI, 0.41-1.11;P = .12). In group 1b, interaction analysis found that age of 64 years or younger, absence of comorbidities, treatment at academic institutions, and distal pancreatic tumors were factors associated with increased survival after surgical resection. Conclusions and Relevance Findings of this study support an association between surgical resection and increased survival in select patients with NF-PanNETs measuring 1.1 to 2.0 cm who were younger than 65 years, had no comorbidities, received treatment at academic institutions, and had tumors of the distal pancreas. Future investigations of surgical resection for small NF-PanNETs that include the Ki-67 index are warranted to validate these findings.

Surgical simulation and video-based learning are limited in lower-resource settings. We sought to develop and assess a series of surgical tutorials using a low-cost simulator. We created 8 surgical skills and procedures videos using low-cost equipment. We assessed video quality using the DISCERN scale and the Global Quality Scale (GQS). Videos ranged from surgical techniques to complex procedures. We uploaded these to Youtube and included them in the curriculum of a medical school in Rwanda. Excluding the cost of the kit (25 USD), production costs ranged from 2 to 5 USD. All videos scored a mean DISCERN of 2.44 ​± ​1.05 and GQS of 3.06 ​± ​0.90. Generally, these lacked points on providing additional sources of information and addressing areas of uncertainty. This study addresses the demand for accessible surgical education resources. Using low-cost, standardized materials ensures consistency, democratization of training, and feasibility. •Developed surgical video tutorials using low-cost and locally sourced materials.•Produced the videos in collaboration with institutions from the USA and Rwanda.•Evaluated online engagement of each video based on reach and retention.•Analyzed the initiative, highlighting both successes and areas for improvement.•Offered actionable recommendations and best practices to improve and increase impact.

Current recommendations using Hounsfield units (HU) ≤ 10 to identify adrenal adenomas on unenhanced computed tomography (CT) miss 10–40% of benign adenomas. We sought to determine if changing HU threshold and adding absolute percent contrast washout (APW) criteria would identify adrenal adenomas better than current recommendations. Imaging characteristics were compared between patients with adenomas (n = 128) and those with non-adenomas (n = 54) after unilateral adrenalectomy. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) were calculated. Using HU ≤ 10 to identify adenomas had a sensitivity of 47.6%, specificity of 93.3% (AUC = 0.71, p < 0.001), PPV of 95.3%, and NPV of 58.1% for identifying adrenal adenomas. Applying HU ≤ 16 improved sensitivity (65.4%) without reducing specificity (93.3%) (AUC = 0.79, p < 0.001), PPV increased to 96.3%, and NPV decreased to 47.6%. Applying HU ≤ 16 as the initial criterion followed by APW > 60% for lesions exceeding 16 HU, sensitivity increased to 93.4%, specificity was 93.3% and PPV 96.6%, and NPV improved to 85.7% (AUC = 0.96, p < 0.001). Criteria of initial threshold of HU ≤ 16 followed by APW > 60% for lesions exceeding 16 HU yielded improved sensitivity and specificity in identification of adrenal adenomas. •A HU ≤ 10 cutoff on a CT has a sensitivity of 47.6% and specificity of 93.3%.•Raising the cutoff to HU ≤ 16 improved sensitivity without detriment to specificity.•An initial criterion of HU ≤ 16 followed by absolute % contrast washout >60% for lesions exceeding 16 HU was optimal. Short Summary: Imaging characteristics on CT imaging can identify benign adrenal masses that do not need further imaging follow up. However, using the current cut-off of HU ≤ 10 only identifies half of benign adenomas. Applying HU ≤ 16 and examining absolute percent contrast washout for lesions exceeding this threshold improves sensitivity to 93.4% and specificity to 93.3% for identification of adrenal adenomas.

Background Incidental adrenal masses (IAMs) occur in approximately 4% of patients undergoing abdominal CT scans for any indication. Hormonal evaluation is recommended for all IAMs. The purpose of this study was to identify the rate of IAMs in a screening population and to determine the adequacy of endocrine evaluation of newly identified IAMs based on established guidelines. Methods This was a retrospective analysis of 6913 patients undergoing a non-contrast screening CT colonography at a single academic medical center between June 2004 and July 2012. Results The prevalence of IAMs in this asymptomatic screening population was 2.1% ( n  = 148). Of those patients, 8.8% ( n  = 11) underwent some form of hormonal evaluation and only 6.4% ( n  = 8) patients had a “complete” workup. Cortisol, metanephrines, and an aldosterone–renin ratio were evaluated in 8.0%, 7.2%, and 4.0% of patients, respectively. Of the patients ( n  = 11) who underwent hormonal evaluation, 27.3% had functional masses and 36.4% underwent surgery. Of those who did not have hormonal evaluation, 42.1% ( n  = 48) had comorbidities that should have prompted hormonal evaluation based on established guidelines. Hormonal evaluation was not performed in 89.4% of patients with hypertension and 21.1% of patients with diabetes. 88.9% of patients on three or more antihypertensive medications did not undergo any hormonal evaluation. Conclusions Compliance with IAM workup guidelines is poor, which may result in missed diagnosis of functional adrenal masses. Establishment of a robust protocol and education on appropriate workup for IAMs is necessary for adequate hormonal evaluation.

Key Points More than half of all patients with cancer receive radiation therapy. Normal tissue tolerance for radiation limits the dose of radiation that can safely be delivered, which can limit the probability of curing a tumour. As our knowledge of the mechanisms and signalling pathways that determine the response of tumour tissues and normal tissues to radiation increases, targeted drugs can be developed that selectively sensitize tumours or protect normal tissues. Promising approaches to selectively enhance tumour radiosensitivity include triggering synthetic lethality, inhibiting multiple targets to simultaneously block more than one signalling pathway and targeting the tumour microenvironment. More than half of all patients with cancer receive radiation therapy, but normal tissue tolerance to radiation often limits the ability to cure tumours with radiation therapy. Here, Moding, Kastan and Kirsch discuss current approaches and possible future directions for combining radiation therapy with targeted therapies to enhance the probability of tumour cure. Approximately 50% of all patients with cancer receive radiation therapy at some point during the course of their treatment, and the majority of these patients are treated with curative intent. Despite recent advances in the planning of radiation treatment and the delivery of image-guided radiation therapy, acute toxicity and potential long-term side effects often limit the ability to deliver a sufficient dose of radiation to control tumours locally. In the past two decades, a better understanding of the hallmarks of cancer and the discovery of specific signalling pathways by which cells respond to radiation have provided new opportunities to design molecularly targeted therapies to increase the therapeutic window of radiation therapy. Here, we review efforts to develop approaches that could improve outcomes with radiation therapy by increasing the probability of tumour cure or by decreasing normal tissue toxicity.

Nutrition exerts considerable effects on health, and dietary interventions are commonly used to treat diseases of metabolic aetiology. Although cancer has a substantial metabolic component 1 , the principles that define whether nutrition may be used to influence outcomes of cancer are unclear 2 . Nevertheless, it is established that targeting metabolic pathways with pharmacological agents or radiation can sometimes lead to controlled therapeutic outcomes. By contrast, whether specific dietary interventions can influence the metabolic pathways that are targeted in standard cancer therapies is not known. Here we show that dietary restriction of the essential amino acid methionine—the reduction of which has anti-ageing and anti-obesogenic properties—influences cancer outcome, through controlled and reproducible changes to one-carbon metabolism. This pathway metabolizes methionine and is the target of a variety of cancer interventions that involve chemotherapy and radiation. Methionine restriction produced therapeutic responses in two patient-derived xenograft models of chemotherapy-resistant RAS-driven colorectal cancer, and in a mouse model of autochthonous soft-tissue sarcoma driven by a G12D mutation in KRAS and knockout of p53 ( Kras G12D /+ ;Trp53 −/− ) that is resistant to radiation. Metabolomics revealed that the therapeutic mechanisms operate via tumour-cell-autonomous effects on flux through one-carbon metabolism that affects redox and nucleotide metabolism—and thus interact with the antimetabolite or radiation intervention. In a controlled and tolerated feeding study in humans, methionine restriction resulted in effects on systemic metabolism that were similar to those obtained in mice. These findings provide evidence that a targeted dietary manipulation can specifically affect tumour-cell metabolism to mediate broad aspects of cancer outcome. In two patient-derived xenograft models of colorectal cancer and a mouse model of autochthonous soft-tissue sarcoma, dietary restriction of methionine influences the outcome of cancer and interacts with antimetabolite and radiation therapies, through effects on one-carbon metabolism.

People with chronic tetraplegia, due to high-cervical spinal cord injury, can regain limb movements through coordinated electrical stimulation of peripheral muscles and nerves, known as functional electrical stimulation (FES). Users typically command FES systems through other preserved, but unrelated and limited in number, volitional movements (eg, facial muscle activity, head movements, shoulder shrugs). We report the findings of an individual with traumatic high-cervical spinal cord injury who coordinated reaching and grasping movements using his own paralysed arm and hand, reanimated through implanted FES, and commanded using his own cortical signals through an intracortical brain–computer interface (iBCI). We recruited a participant into the BrainGate2 clinical trial, an ongoing study that obtains safety information regarding an intracortical neural interface device, and investigates the feasibility of people with tetraplegia controlling assistive devices using their cortical signals. Surgical procedures were performed at University Hospitals Cleveland Medical Center (Cleveland, OH, USA). Study procedures and data analyses were performed at Case Western Reserve University (Cleveland, OH, USA) and the US Department of Veterans Affairs, Louis Stokes Cleveland Veterans Affairs Medical Center (Cleveland, OH, USA). The study participant was a 53-year-old man with a spinal cord injury (cervical level 4, American Spinal Injury Association Impairment Scale category A). He received two intracortical microelectrode arrays in the hand area of his motor cortex, and 4 months and 9 months later received a total of 36 implanted percutaneous electrodes in his right upper and lower arm to electrically stimulate his hand, elbow, and shoulder muscles. The participant used a motorised mobile arm support for gravitational assistance and to provide humeral abduction and adduction under cortical control. We assessed the participant's ability to cortically command his paralysed arm to perform simple single-joint arm and hand movements and functionally meaningful multi-joint movements. We compared iBCI control of his paralysed arm with that of a virtual three-dimensional arm. This study is registered with ClinicalTrials.gov, number NCT00912041. The intracortical implant occurred on Dec 1, 2014, and we are continuing to study the participant. The last session included in this report was Nov 7, 2016. The point-to-point target acquisition sessions began on Oct 8, 2015 (311 days after implant). The participant successfully cortically commanded single-joint and coordinated multi-joint arm movements for point-to-point target acquisitions (80–100% accuracy), using first a virtual arm and second his own arm animated by FES. Using his paralysed arm, the participant volitionally performed self-paced reaches to drink a mug of coffee (successfully completing 11 of 12 attempts within a single session 463 days after implant) and feed himself (717 days after implant). To our knowledge, this is the first report of a combined implanted FES+iBCI neuroprosthesis for restoring both reaching and grasping movements to people with chronic tetraplegia due to spinal cord injury, and represents a major advance, with a clear translational path, for clinically viable neuroprostheses for restoration of reaching and grasping after paralysis. National Institutes of Health, Department of Veterans Affairs.

The development of new materials and their compositional and microstructural optimization are essential in regard to next-generation technologies such as clean energy and environmental sustainability. However, materials discovery and optimization have been a frustratingly slow process. The Edisonian trial-and-error process is time consuming and resource inefficient, particularly when contrasted with vast materials design spaces 1 . Whereas traditional combinatorial deposition methods can generate material libraries 2 , 3 , these suffer from limited material options and inability to leverage major breakthroughs in nanomaterial synthesis. Here we report a high-throughput combinatorial printing method capable of fabricating materials with compositional gradients at microscale spatial resolution. In situ mixing and printing in the aerosol phase allows instantaneous tuning of the mixing ratio of a broad range of materials on the fly, which is an important feature unobtainable in conventional multimaterials printing using feedstocks in liquid–liquid or solid–solid phases 4 – 6 . We demonstrate a variety of high-throughput printing strategies and applications in combinatorial doping, functional grading and chemical reaction, enabling materials exploration of doped chalcogenides and compositionally graded materials with gradient properties. The ability to combine the top-down design freedom of additive manufacturing with bottom-up control over local material compositions promises the development of compositionally complex materials inaccessible via conventional manufacturing approaches. The authors report a high-throughput combinatorial printing method capable of fabricating materials with compositional gradients at microscale spatial resolution, demonstrating a variety of high-throughput printing strategies and applications in combinatorial doping, functional grading and chemical reaction.

Consumer sleep technologies (CSTs) are widespread applications and devices that purport to measure and even improve sleep. Sleep clinicians may frequently encounter CST in practice and, despite lack of validation against gold standard polysomnography, familiarity with these devices has become a patient expectation. This American Academy of Sleep Medicine position statement details the disadvantages and potential benefits of CSTs and provides guidance when approaching patient-generated health data from CSTs in a clinical setting. Given the lack of validation and United States Food and Drug Administration (FDA) clearance, CSTs cannot be utilized for the diagnosis and/or treatment of sleep disorders at this time. However, CSTs may be utilized to enhance the patient-clinician interaction when presented in the context of an appropriate clinical evaluation. The ubiquitous nature of CSTs may further sleep research and practice. However, future validation, access to raw data and algorithms, and FDA oversight are needed. Citation: Khosla S, Deak MC, Gault D, Goldstein CA, Hwang D, Kwon Y, O'Hearn D, Schutte-Rodin S, Yurcheshen M, Rosen IM, Kirsch DB, Chervin RD, Carden KA, Ramar K, Aurora RN, Kristo DA, Malhotra RK, Martin JL, Olson EJ, Rosen CL, Rowley JA; American Academy of Sleep Medicine Board of Directors. Consumer sleep technology: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018;14(5):877–880.