A Systematic Review And Meta-Analysis

[Posted 17/May/2022]

AUDIENCE: Emergency Medicine, Pediatric

KEY FINDINGS: The present systematic review and meta-analysis showed that POCUS had high sensitivity and specificity for identifying testicular torsion in paediatric patients although the risk of bias was high in the studies analysed.

BACKGROUND: Previous studies have examined the utility of ultrasonography performed by radiologists for diagnosing paediatric testicular torsion. While point-of-care ultrasound (POCUS) is used in paediatric emergency medicine, its diagnostic accuracy is still unknown. The present systematic review and meta-analysis aimed to clarify the accuracy of POCUS in diagnosing testicular torsion in children.

DETAILS: Following the Preferred Reporting Items for Systematic Review and Meta-analysis of Diagnostic Test Accuracy guidelines, a systematic review was performed. Any study investigating the diagnostic accuracy of POCUS for paediatric testicular torsion was extracted. The primary outcome was the assessment of the diagnostic accuracy of POCUS for paediatric testicular torsion. The pooled sensitivity and specificity were calculated. Quality analysis was conducted using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). Four studies enrolling 784 patients in total were included. The pooled sensitivity, specificity, and positive and negative likelihood ratios of POCUS were 98.4% (95% CI: 88.5% to 99.8%), 97.2% (95% CI: 87.2% to 99.4%), 34.7 (95% CI: 7.4 to 164.4) and 0.017 (95% CI: 0.002 to 0.12), respectively. Risk-of-bias assessment using QUADAS-2 revealed that two of the studies had a high risk of bias in patient selection.

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Source: Mori, T., Ihara, T., Nomura, O. (2022). Diagnostic Accuracy Of Point-Of-Care Ultrasound For Paediatric Testicular Torsion: A Systematic Review And Meta-Analysis. Emergency Medicine Journal . 2022; e212281. Published: May 6, 2022. DOI: 10.1136/emermed-2021-212281.

A Paradigm for Healthy Aging

[Posted 6/Oct/2026]

AUDIENCE: Ob/Gyn, Endocrinology, Internal Medicine

KEY FINDINGS: Key Information The FIGO-IMS position paper reframes hormone therapy in POI and early menopause as replacement of prematurely lost ovarian hormones, with potential implications for healthy aging. Treatment decisions should consider age at ovarian insufficiency, symptoms, bone health, cardiovascular risk, uterine status, reproductive goals, and individual contraindications.

The evidence supports a comprehensive, individualized approach rather than assuming that regimens used for typical-age menopause are sufficient for younger women with prolonged estrogen deficiency. The authors also acknowledge important evidence gaps, particularly regarding long-term cardiovascular outcomes and comparative effectiveness of different hormone regimens.

BACKGROUND: Premature ovarian insufficiency (POI) and early menopause are associated with prolonged estrogen deficiency during years when ovarian hormone production would ordinarily continue. Beyond vasomotor symptoms and reproductive consequences, estrogen deficiency may affect skeletal, cardiovascular, metabolic, cognitive, and genitourinary health. Hormone therapy (HT) has traditionally been considered primarily for symptom control, but its role in replacing deficient ovarian hormones and supporting long-term health warrants broader clinical consideration.

A joint position paper from FIGO and the International Menopause Society (IMS) reviews current evidence and proposes a more comprehensive approach to hormone therapy in women with POI or early menopause.

DETAILS: The position paper examines the physiological rationale for estrogen replacement, the timing and duration of treatment, hormone formulation and route of administration, and the potential implications for bone and cardiovascular health. It discusses the distinction between hormone replacement in younger women with premature estrogen loss and conventional menopausal hormone therapy initiated around the usual age of menopause. The authors review evidence supporting physiological estradiol replacement, including transdermal 17β-estradiol at 100 micrograms per day or oral 17β-estradiol at 2-4 mg per day. The paper also addresses the need for progestogen protection in women with an intact uterus, individualization of treatment, fertility considerations, and the limitations of available evidence concerning long-term cardiovascular outcomes and comparisons between HT and combined oral contraceptives.

The position paper emphasizes that hormone therapy in women with POI or early menopause should be considered an important component of long-term health management, rather than solely a treatment for vasomotor symptoms. Physiological estrogen replacement may help maintain bone mineral density and address consequences of premature estrogen deficiency. The authors discuss evidence that transdermal estradiol at 100 micrograms per day can restore lumbar spine and femoral neck bone mineral density to normal levels in women with POI. However, evidence regarding the superiority of higher estrogen doses for all skeletal outcomes remains inconsistent, and comparative data on major cardiovascular outcomes are limited.

The paper also highlights the need for further research comparing hormone therapy with combined oral contraceptives and evaluating long-term health outcomes, treatment acceptability, and optimal regimens.

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Source: Benedetto, C., Khadilkar, S. S., Nappi, R. E., et al. Hormone therapy (HT) in women with premature ovarian insufficiency or early menopause: Time to think of a new paradigm for healthy aging. Journal of Gynecology & Obstetrics.. 2026; 175(1): 26-47. Published: October, 2026. DOI: 10.1002/ijgo.71217.

[Posted 1/Oct/2026]

AUDIENCE: Nephrology, Endocrinology, Emergency Medicine

KEY FINDINGS: In this European cohort of older adults with ESKD, vascular access creation frequently did not coincide with the timing of hemodialysis initiation. More than 4 in 10 AVFs were created early, while approximately 1 in 4 were created late, resulting in substantial use of CVCs at dialysis initiation. The findings highlight the difficulty of predicting dialysis initiation in older adults and support the development of clinical prediction tools to better individualize vascular access planning.

BACKGROUND: Planning vascular access for older adults with end-stage kidney disease (ESKD) is challenging because the timing of hemodialysis initiation is difficult to predict. Arteriovenous fistulas (AVFs) created too early may remain unused, whereas delayed creation can result in hemodialysis being initiated through a central venous catheter (CVC). This study evaluated the timing of vascular access creation relative to hemodialysis initiation in older patients across Europe.

DETAILS: This secondary analysis used data from the EQUAL cohort, a prospective observational study involving patients aged 65 years or older with stage 4 or 5 chronic kidney disease in six European countries. Patients were included when their estimated glomerular filtration rate fell below 15 mL/min/1.73 m², provided they received a vascular access and had at least 6 months of follow-up. AVF timing was categorized as early when hemodialysis did not begin within 6 months after AVF creation, on time when hemodialysis was initiated with an AVF within 6 months, and late when hemodialysis was initiated with a CVC before or within 6 months after AVF creation.

A total of 332 patients were analyzed. An AVF was the first vascular access in 221 patients (67%), while 111 patients (33%) initially received a CVC. Among those initially receiving a CVC, 53 patients (48%) subsequently underwent AVF creation. At dialysis initiation, 158 patients (54%) were using an AVF and 136 (46%) were using a CVC. Among the 274 patients who underwent AVF creation, access was created on time in 88 patients (32%), early in 114 (42%), and late in 72 (26%). Despite the high proportion of early AVF creation, most fistulas were eventually used, with 90% of patients initiating hemodialysis within 3 years after AVF creation.

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Source: Heggen, B. D. C., Chesnaye, N. C., Dekker, F. W., et al. Vascular Access Surgery Timing: A Prospective European Cohort Study in Elderly Patients with ESKD. Kidney360. 2026; 7(9): 2066-2074. Published: September 22, 2026. DOI: 10.34067/KID.0000001180.

[Posted 25/Sep/2026]

AUDIENCE: Critical Care Nursing, Palliative Hospice Nursing

KEY FINDINGS: A structured, interprofessional approach to palliative ECMO de-escalation can reduce variability in end-of-life practice and support more consistent symptom management and communication. Incorporating patient and family preferences into the process, together with proactive symptom management and staff debriefing, was associated with a more comfortable and dignified end-of-life experience in this quality-improvement setting.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an invasive, potentially lifesaving therapy associated with complications involving multiple organ systems. When ECMO is no longer considered beneficial, de-escalation or decannulation may be required as part of a transition to comfort-focused care and natural death. At a tertiary care facility with 64 beds using ECMO, variability was identified in ECMO initiation, communication with patients and families, determination of nonbeneficial therapy, and symptom management during de-escalation.

DETAILS: This quality-improvement project integrated palliative care, reviewed existing literature on best practices, and established an interprofessional task force focused on ECMO de-escalation. New clinical guidelines were developed to provide a consistent, evidence-based framework for communication, decision-making, symptom management, and de-escalation/decannulation. The initiative was designed to reduce practice variability while improving the experience of patients, families, and clinicians during transition to comfort-directed care.

Implementation of the guidelines decreased practice variability and reduced patient and family stress and discomfort during ECMO de-escalation and decannulation. Team members reported decreases in symptoms of secondary trauma and moral distress associated with these situations. They also reported improved delivery of end-of-life care, including family education and support, patient advocacy, and symptom management. Family members valued greater attention to both patient and family well-being, while structured staff debriefings supported reflection and identification of opportunities for improvement.

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Source: Arbour, R., Abate, M., Garcia, O., et al. Palliative Extracorporeal Membrane Oxygenation Decannulation: An Ethical, Evidence-Based Approach. Critical Care Nurse. 2026; 46(4): 17-28. Published: August 1, 2026. DOI: 10.4037/ccn2026166.

[Posted 23/Sep/2026]

AUDIENCE: Cardiology, Oncology, Internal Medicine

KEY FINDINGS: In this large real-world cohort of patients with early-stage HER2-positive breast cancer, biosimilar trastuzumab use increased markedly between 2018 and 2024 without a statistically significant difference in heart failure risk compared with reference trastuzumab. Overall heart failure occurred in 5.9% of the study population. Comorbidity burden and older age were associated with higher heart failure risk, emphasizing the importance of cardiovascular risk assessment during HER2-directed therapy. Because this was a retrospective claims-based study, longer follow-up and additional real-world studies are needed to further evaluate long-term cardiac outcomes.

BACKGROUND: Trastuzumab is an important treatment for HER2-positive breast cancer, but cardiac dysfunction, including heart failure, remains a recognized safety concern. Biosimilar trastuzumab products have expanded treatment access and may reduce costs, although real-world data comparing their cardiac safety with the reference product remain limited. This study evaluated the uptake of biosimilar trastuzumab and compared heart failure risk between patients receiving biosimilar and reference trastuzumab in routine clinical practice.

DETAILS: The investigators analyzed patients aged ≥18 years with breast cancer who received trastuzumab between 2018 and 2024 using the IQVIA PharMetrics Plus Closed Health Plan Claims database. Patients who underwent breast cancer surgery within the first year after diagnosis were considered to have early-stage disease. Individuals with a heart failure diagnosis before breast cancer surgery were excluded. Trastuzumab products were identified using Healthcare Common Procedure Coding System Level II codes, while heart failure was identified using International Classification of Diseases codes. The analysis used multivariable cause-specific Cox proportional hazards regression to evaluate the association between trastuzumab type and subsequent heart failure risk. The study included 5,135 patients, of whom 43.9% received reference trastuzumab.

Use of biosimilar trastuzumab increased substantially during the study period, from 0% in 2018 to 71.3% in 2024 (P<0.001). Overall, heart failure occurred in 5.9% of patients, including 5.5% of those receiving reference trastuzumab and 6.3% of those receiving biosimilar trastuzumab (P=0.26). After adjustment for relevant factors, there was no statistically significant difference in heart failure risk between biosimilar and reference trastuzumab (adjusted HR, 1.16; 95% CI, 0.92-1.46). In contrast, patients with a Charlson Comorbidity Index score ≥2 had a higher heart failure risk than those with a score of 0 (adjusted HR, 1.52; 95% CI, 1.11-2.08). Older age was also associated with greater risk: compared with patients aged 18-54 years, the adjusted HR was 1.61 (95% CI, 1.19-2.19) for those aged 65-74 years and 1.95 (95% CI, 1.29-2.96) for those aged ≥75 years.

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Source: Jackson, I., Zhang, N., Sullivan, M., et al. Real-World Cardiotoxicity of Biosimilar versus Reference Trastuzumab in Early HER2-Positive Breast Cancer. JACC: CardioOncology. Published: September 10, 2026. DOI: 10.1016/j.jaccao.2026.07.009.

[Posted 21/Sep/2026]

AUDIENCE: Emergency Medicine, Pediatrics

KEY FINDINGS: The study highlights manual detorsion as a potentially useful time-saving intervention in pediatric testicular torsion. Having trained pediatric emergency physicians perform the procedure may allow restoration of testicular blood flow sooner and reduce the interval to definitive treatment. Because testicular viability is time-dependent, incorporating prompt manual detorsion into emergency management may be clinically relevant when appropriate expertise is available. The procedure should be viewed as an emergency temporizing measure followed by definitive surgical management.

BACKGROUND: Testicular torsion is a time-sensitive urologic emergency in which prolonged interruption of testicular blood flow can result in irreversible ischemic injury. Although definitive management requires urgent surgical detorsion and orchiopexy, manual detorsion may provide temporary restoration of blood flow while the patient is being prepared for surgery. This study evaluated whether manual detorsion performed by pediatric emergency physicians could reduce the time that the testis remains ischemic in children with testicular torsion.

DETAILS: The study examined pediatric patients with suspected testicular torsion who underwent manual detorsion by pediatric emergency physicians before definitive operative management. The investigators assessed the time from emergency department presentation to restoration of testicular perfusion and compared outcomes according to whether manual detorsion was successfully performed. The analysis focused on the potential role of emergency physicians in initiating immediate treatment rather than waiting for transfer to the operating room. Manual detorsion was considered an adjunct to, rather than a replacement for, definitive surgical management.

Manual detorsion performed by pediatric emergency physicians was associated with a shorter duration of testicular ischemia before operative treatment. Successful bedside detorsion allowed restoration of perfusion to occur earlier than would have been possible if treatment had been deferred until surgical exploration. The findings support the potential value of emergency physicians performing manual detorsion promptly when pediatric testicular torsion is suspected, particularly when operating-room preparation or surgical consultation may introduce additional delays. Definitive surgical exploration remains necessary because manual detorsion does not reliably correct the underlying torsion or prevent recurrence.

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Source: Rivera, T., Lozano, J., Maniaci, V., et al. Manual Detorsion by Pediatric Emergency Physicians Shortens Ischemia Time in Pediatric Testicular Torsion. Academic Emergency Medicine. 2026; 33(9): e70412. Published: September, 2026. DOI: 10.1111/acem.70412.