School of Medicine

Purpose of ReviewTailoring treatment strategies to the biological features of invasive disease and the individual needs and preference of each patient has transformed the way we manage breast cancer. This article calls for a similar shift in the management paradigm of ductal carcinoma in situ (DCIS) from a uniform treatment model toward a risk-stratified stepwise approach that aligns with the heterogeneous nature of the disease to avoid overtreatment.Recent FindingsMost DCIS lesions are hormone receptor positive, and only a subset have a risk for progression to invasive cancer. Early results from observational and clinical studies indicate that active surveillance is a safe and feasible alternative to upfront surgical treatment for low-risk DCIS. Ongoing clinical trials like RECAST will further inform and refine strategies for optimal management of this condition.SummaryThe integration of risk-adapted management strategies, endocrine risk-reducing interventions, and advanced imaging modalities into active surveillance protocols hold significant potential to reduce overtreatment and personalize care for patients with DCIS. Early data from clinical trials support the notion that providing a period of active surveillance is safe and offers a critical assessment window during which DCIS treatment can be individualized. Strengthening the evidence base to support the adoption of active surveillance as an initial approach in the management of DCIS is an important clinical priority.

HLA sensitization poses a major challenge to kidney transplantation for patients with end-stage kidney disease, especially for highly sensitized candidates. Attempts at antibody elimination (desensitization) have had inconsistent efficacy and have often failed to produce sustained reductions in anti-HLA antibodies in patients with the highest level of sensitization (calculated panel-reactive antibody score, ≥99.9%). We now report the results for the safety run-in cohort of a multicenter phase 1 clinical study evaluating the safety and efficacy of combined CD19-targeted and B-cell maturation antigen (BCMA)-targeted chimeric antigen receptor (CAR) T cells in eliminating the cellular sources of preformed anti-HLA antibodies (ClinicalTrials.gov number, NCT06056102). Kidney transplantation was performed in two highly sensitized candidates after desensitization with the use of dual CAR T-cell therapy.

The neural crest generates a broad spectrum of cell types that migrate across the body plan to populate multiple tissues1. However, the relationship between lineages of neural crest derivatives remains unclear, and the extent to which neural crest cells delaminated from the neural tube have specified fates remains debated. Here, leveraging CRISPR barcoding in mice and mosaic variant barcode analysis in humans, we demonstrate robust bilateral progenitor clonal spread of neural crest progenitors along the rostrocaudal axis but limited clonal overlap between sensory and sympathetic lineages. Computational modelling of mosaic variants suggests that most neural crest cells show strong fate restriction before delamination. Real-time imaging of quail embryos further shows a fibroblast-growth-factor-dependent rostrocaudal dispersion of neural crest cells across multiple axial levels. These findings support a model in which neural crest fate bias predominantly emerges within the neural tube, with only a minor subset of delaminated progenitors retaining multipotency to generate both sensory and sympathetic derivatives.

BACKGROUND: Military trauma/surgical critical care (T/SCC) surgeons perform both clinical "inside-the-tent" (ITT) and leadership/administrative "outside-the-tent" (OTT) responsibilities during forward deployments. Despite these demands, fellowship programs lack a standardized curriculum addressing the full spectrum of military-specific requirements. This study evaluates military T/SCC surgeons' perceptions of training quality, satisfaction, and confidence in managing deployment trauma situations, and readiness to assume leadership roles. METHODS: A survey was distributed to all current military T/SCC fellows and attendings to evaluate their perception of ITT and OTT skill training during fellowship. Respondents reported their satisfaction with fellowship training, as well as their confidence, satisfaction, and frequency with which they practiced on ITT and OTT skills. Attendings were additionally asked how often they utilized OTT skills and assumed key OTT leadership positions, such as unit commander or deputy commander, trauma director, or chief medical officer, during deployments. RESULTS: Ninety-four military T/SCC surgeons (80% attendings and 20% fellows) participated; 68% had deployed after fellowship. Confidence in core ITT skills, such as damage control surgery and resuscitation, was high (99% for both), but confidence was low for thoracic (58%) and complex liver trauma procedures (53%). Exposure to OTT domains-triage, systems, and tactical leadership-was limited; fewer than one-third of respondents reported frequent exposure or satisfaction with OTT training during fellowship. However, 84% of attendings frequently performed OTT functions during deployment. Previously deployed surgeons showed significantly greater confidence in disaster management (69% vs. 42%; p<0.05) and tactical decision-making (75% vs. 46%; p<0.05) OTT skills. CONCLUSIONS: While operative training was viewed favorably, many surgeons felt clinically confident but underprepared for deployment leadership roles. Greater OTT confidence among previously deployed surgeons suggests that operational experience-not fellowship training-currently drives proficiency. A military-specific curriculum is needed to prepare surgeons for leadership responsibilities in combat settings. (J Trauma Acute Care Surg. 2026;00:00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level IV.

Background Prophylactic postoperative vasopressors (PPV) are used to induce hemodynamic augmentation to prevent spinal cord ischemia (SCI) in patients undergoing thoracic endovascular aortic repair (TEVAR). However, the scientific evidence on its effectiveness and safety is limited. This study aims to investigate the safety and effectiveness of PPV in patients undergoing TEVAR in a multi-institutional real-world setting. Methods All TEVAR patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) database between March 1, 2012, and January 28, 2023, were identified. Univariable and multivariable analyses were performed to assess the association between the use of PPV and the rates of postoperative 30-day mortality, Major Adverse Cardiovascular Events (MACE, defined as new onset of postoperative myocardial infarction (MI), congestive heart failure (CHF), dysrhythmias, or stroke), SCI, and other adverse events for patients undergoing TEVAR. Results Out of 25,549 reviewed patients, 11,342 underwent TEVAR, matching the study criteria, and were analyzed. 2,420 patients (21.3%) received PPV. Patients who received PPV had significantly higher rates of 30-day mortality (9.3% vs 2.1%, p<0.001), MACE (18.2% vs 7.4%, p<0.001), postoperative SCI (2.6% vs 1.3%, p<0.001), and other adverse events. After adjusting for confounders, the use of PPV was associated with significantly increased odds of 30-day mortality (OR, 3.23, 95%CI: 2.58-4.04, p<0.001), MACE (OR, 2.18, 95%CI: 1.89-2.51, p<0.001), postoperative SCI (OR, 1.46, 95%CI: 1.05-2.01, p=0.022) and other adverse events. Conclusions PPV was associated with significantly higher odds of 30-day mortality, MACE, SCI, and other adverse outcomes. The role of PPV should be re-evaluated, and the decision for administration should be made on an individualized basis, considering patient comorbidities and risk factors. A prospective study is required to confirm these findings.

PURPOSE: Medical students feel inadequately prepared to cope with patient death. Simulation training may provide learners with the opportunity to experience death in a safe environment with a structured debriefing. METHODS: Nineteen fourth-year medical students who matched into surgical specialties participated in a 2-week surgical intern preparatory course. During an individual surgical decision-making simulation, 6 learners experienced unexpected patient death at the hands of a facilitator who deviated from the simulation script. Subjectively, these learners displayed high anxiety before the debriefing. Objectively, their self-reported anxiety after the structured debriefing was similar to the self-reported anxiety of learners who did not experience simulation death. RESULTS: We formalized a bi-directional debriefing instrument using the Gather Analyze Summarize (GAS) model as a framework. We recognized that learners who experienced simulation death need to debrief on 2 aspects of the simulation: 1) Simulation death and 2) Scientific content. CONCLUSION: Our unexpected experience with simulation death led to the development of a debriefing tool that can be used by other surgical educators. Learning how to process the ensuing emotional response to patient death in simulation may benefit trainees provided they undergo a structured debriefing.

BACKGROUND: Fenestrated/branched endovascular aortic repair (F/BEVAR) with commercially available devices require a paravisceral segment >20 mm. We compared commercial and physician-modified F/BEVAR outcomes in a narrowed flow lumen (NFL, <20 mm) to a standard flow lumen (SFL, ≥20 mm). METHODS: We conducted a retrospective review of F/BEVAR repairs between 2016 and 2024. Primary outcome was technical success, and secondary endpoints were target vessel stability, type 1/3 endoleaks requiring reintervention, and major adverse events (MAEs). RESULTS: A total of 136 patients underwent 138 repairs (75% male, 74 ± 10 years), 35 repairs (25%) were in NFL and 103 (75%) in SFL. Median visceral segment diameter was 24 mm (interquartile range [IQR] 19-29; 16 mm, IQR 15-18 in NFL; 28 mm, IQR 23-30 in SFL, P < 0.001). We observed 99% technical success. Mean fenestrations per repair was higher in NFL (3.1 vs. 1.5, P < 0.001), and mean branches was higher in SFL (2.1 vs. 0.7, P < 0.001). There were 24 (17%; 2 in NFL, 22 in SFL, P = 0.035) MAEs. There were nine branch vessel occlusions (three in NFL, six in SFL, P = 0.463) at a median follow-up of 516 days. Target vessel stability (86% in NFL vs. 84% in SFL, P = 0.757) and rate of reinterventions (2, 6% in NFL; 14, 14% in SFL, P = 0.209) did not differ significantly. CONCLUSION: Custom F/BEVAR offers equivalent outcomes in complex anatomy with narrowed paravisceral flow lumens compared to on-label branched and fenestrated repairs in SFLs. Early results demonstrate reasonable target vessel stability and freedom from reintervention, though additional follow-up is needed.

PURPOSE: Neonatal bowel obstruction secondary to inspissated meconium has been historically associated with cystic fibrosis. Increasingly, meconium-related obstruction (MRO) has been observed in preterm infants. We conducted a multicenter mixed-methods study to better characterize the contemporary experience with MRO. METHODS: A retrospective cohort study of infants with MRO was performed at seven children's hospitals from 2018 to 2022. Chi-squared tests, Kruskal-Wallis tests, and logistic regression were used to assess the association of cystic fibrosis, Hirschsprung disease, and prematurity with treatment strategies and clinical outcomes of MRO. Providers were surveyed regarding their management of MRO of prematurity. RESULTS: We identified 105 infants treated for MRO, including 54 (51 %) with MRO of prematurity, 16 (15 %) with Hirschsprung disease, 6 (6 %) with cystic fibrosis, and 29 (28 %) with MRO of the term infant. Overall, 32 % (n = 34) received glycerin suppositories, 25 % (n = 26) rectal irrigation, 79 % (n = 83) contrast enemas, and 6 % (n = 6) retrograde or antegrade N-acetylcysteine. Twenty-seven (26 %) infants required surgery for MRO, of whom 21 (78 %) had MRO of prematurity. For infants with MRO of prematurity, a one-week increase in gestational age was associated with a 23 % decrease in the odds of requiring surgery (OR = 0.77; 95%CI = 0.64-0.93). Survey responses from 42 providers suggested limited institutional treatment algorithms for MRO. CONCLUSION: In this multi-institutional study, most cases of MRO were associated with prematurity. Extent of prematurity was associated with a higher likelihood of requiring surgery. Results from this contemporary cohort study and survey provide a framework for developing a prevention and treatment algorithm for MRO of prematurity.

Background This study evaluates impact of converting from local to general anesthesia on Transcarotid Artery Revascularization (TCAR) outcomes and identifies risk factors predictive of conversions. Methods 58,960 TCAR cases from the Vascular Quality Initiative (2018–2024) were categorized by anesthesia type: 6,831 local/regional (LRA), 51,851 general (GA), and 278 conversions from LRA to GA. In-hospital outcomes were compared using multivariate logistic regression, with stroke/death as the primary endpoint. Preoperative predictors of conversion were also assessed. Results Converted patients were oldest, more often obese, and more likely to undergo urgent procedures. Compared to LRA, conversion was associated with increased odds of in-hospital stroke/death (aOR = 3.01; 95% CI, 1.54-5.36; P < 0.001), stroke/death/MI (aOR = 2.92; 95% CI, 1.58-5.00; P < 0.001), and prolonged hospital stay (aOR = 1.38; 95% CI, 1.05-1.80; P = 0.020). Compared to GA, converted patients had higher odds of stroke/death (aOR = 2.95; 95% CI, 1.55-5.09; P < 0.001) and stroke/death/MI (aOR = 2.75; 95% CI, 1.52-4.57; P < 0.001). Compared to LRA, GA was only associated with longer hospital stay. Age and urgent procedures were significant preoperative predictors of conversion to GA (P < 0.05). Conclusions Conversion from LRA to GA during TCAR is associated with higher rates of stroke, death, and MI compared to LRA or initial GA. Age and urgent TCAR procedures were identified as critical preoperative factors influencing conversion risk. These findings underscore the importance of meticulous preoperative risk assessment and optimal anesthesia selection to minimize conversions and enhance safety in TCAR.