IUD-related Uterine Perforation Incidence and Risk (Apex-IUD)
IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to assure an IUD insertion can occur.
KEY FINDINGS: Although the risk for uterine perforation with IUD insertion 4 days to 6 weeks or less post partum is nearly seven times that of insertion non-post partum, perforation remains an incredibly rare event for all clinical time points. Despite a slight increased risk of perforation with breastfeeding at IUD insertion, the benefits of breastfeeding and effective contraception generally outweigh risks and should have little clinical impact. Therefore, IUD insertion timing should be based on individual desire for IUD contraception and patient convenience to assure an IUD insertion can occur. Careful follow-up of individuals at higher risk of uterine perforation is warranted.
BACKGROUND: Reports of perforation risk related to intrauterine devices (IUDs) inserted immediately post partum and among non-post-partum individuals are scarce, and previous studies with only 12-month follow-ups underestimate the risk. Breastfeeding at IUD insertion and insertion within 36 weeks post partum have been associated with increased risk of uterine perforation. The aim of these analyses was to compare the incidence and risks of IUD-related uterine perforations by non-post-partum and post-partum intervals at IUD insertion, and among post-partum individuals, to assess the impact of breastfeeding on these outcomes.
DETAILS: Performed a multisite cohort study in the USA, using electronic health records (EHR). Study sites were three health-care systems and a site that used data from a health-care information exchange. The study population included individuals who were aged 50 years or younger and had an IUD insertion between Jan 1, 2001, and April 30, 2018. Individuals were excluded if they had not been in the health-care system for at least 12 months before IUD insertion. The primary outcome for this analysis was any IUD-related uterine perforation diagnosis for the first IUD insertion in this time period. Both complete and partial IUD-related perforations were identified. Chart abstraction was done to validate EHR-based algorithms or confirm perforations. The crude rate and cumulative incidence of uterine perforation were evaluated by non-post-partum and post-partum intervals at IUD insertion in the full cohort, and by breastfeeding status in a subcohort of post-partum individuals. Cox models estimated crude and adjusted hazard ratios (aHRs). Data from 326,658 individuals in the full cohort and 94,817 individuals in the post-partum subcohort were analysed. In the full cohort, we identified 1008 uterine perforations (51.2% complete), with the 5-year cumulative incidence being the lowest in the non-post-partum group (0.29%, 95% CI 0.26-0.34). The aHR for the post-partum interval relative to non-post partum ranged from 2.73 (95% CI 1.33-5.63; 0 to 3 days post partum) to 6.71 (4.80-9.38; 4 days to >=6 weeks post partum). The post-partum subcohort of individuals with breastfeeding information had 673 uterine perforations (62% complete), with a 5-year cumulative incidence of 1.37% (95% CI 1.24-1.52) and an increased risk with breastfeeding (aHR 1.37, 95% CI 1.12-1.66).
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Source: Reed, S. D., Zhou, X., Ichikawa, L., et al. (2022). Intrauterine Device-related Uterine Perforation Incidence And Risk (Apex-Iud): A Large Multisite Cohort Study. The Lancet. 2022; 399(10341): 2103-2112. Published: June 4, 2022. DOI: 10.1016/S0140-6736(22)00015-0.
Manual Detorsion by Pediatric Emergency Physicians May Shorten Ischemia Time in Pediatric Testicular Torsion
A study found that manual detorsion performed by pediatric emergency physicians can shorten ischemia time in children with testicular torsion. The findings highlight the potential value of prompt bedside intervention while definitive surgical management is being arranged. Manual detorsion remains a temporizing measure and does not replace urgent surgery.
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.
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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.
Global Differences in Pediatric Trauma Care Linked to Markedly Higher Mortality in Lower-Resource Settings
An international study of 237 children undergoing trauma laparotomy across 85 hospitals in 32 countries found substantial differences in access to timely surgery, senior clinicians, and perioperative resources. Overall 30-day in-hospital mortality was 8%, but children treated in lower-HDI settings had nearly sixfold higher adjusted odds of postoperative death than those in upper-HDI settings. The findings highlight major global disparities in pediatric trauma care and the need for dedicated, appropriately resourced pediatric trauma pathways.
KEY FINDINGS: The study demonstrates substantial international variation in pediatric trauma laparotomy pathways, particularly in prehospital delays, access to senior surgical and anesthesia providers, and available resources. Although crude 30-day mortality was 8% overall, children treated in lower-HDI settings had nearly sixfold higher adjusted odds of postoperative death than those in upper-HDI settings. The findings highlight disparities across the entire trauma-care pathway rather than differences attributable solely to operative management. The authors emphasize the need for trauma systems specifically designed around the physiological, surgical, and developmental needs of children.
BACKGROUND: Traumatic injury is a major cause of death and disability among children and adolescents worldwide, yet pediatric trauma systems and access to specialized care vary substantially between countries. This international study examined differences in injury patterns, treatment pathways, operative care, and postoperative outcomes among children requiring emergency laparotomy after traumatic injury.
DETAILS: The study was a planned post-hoc analysis of the international, multicentre, prospective GOAL-Trauma cohort, which collected data between April 1 and December 31, 2024. Patients aged 18 years or younger with blunt or penetrating trauma who underwent laparotomy within 5 days of presentation were eligible. Hospitals were grouped according to the Human Development Index (HDI) of their setting. A total of 237 pediatric patients from 85 hospitals across 32 countries met the inclusion criteria. Of these, 110 patients were treated in lower-HDI settings, 89 in middle-HDI settings, and 38 in upper-HDI settings. The investigators assessed differences in time to presentation, decision-making and surgery, perioperative interventions, staffing, injury severity, and 30-day in-hospital mortality.
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The timing of trauma care differed substantially across HDI groups. Median time from injury to presentation, decision to operate, and operation itself was significantly longer in lower-resource settings, with the greatest variation occurring before hospital arrival. Overall median time from injury to operation was 7.4 hours (IQR 3.5-18.8). There were also major differences in the resources available during surgery. A consultant or attending general surgeon was the most senior surgeon present for 59% of cases in lower-HDI settings, compared with 78% in middle-HDI and 97% in upper-HDI settings. Similarly, a consultant or attending anesthetist was present in 35%, 62%, and 95% of cases, respectively. The overall crude 30-day in-hospital mortality was 8% (19 of 237 patients). After adjustment for relevant factors, children treated in the lower-HDI group had substantially higher postoperative mortality than those in the upper-HDI group, with an adjusted odds ratio of 5.69 (95% CI 1.58-20.44; P=0.0079).
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Source: Aziz, R., Bath, M. F., Abdelmohsen, S. M., et al. Global variation in injury patterns, interventions, and post-operative outcomes for children and adolescents undergoing trauma laparotomy: an international cohort study. The Lancet Child & Adolescent Health. 2026; 10(7): 505-514. Published: May 7, 2026. DOI: 10.1016/S2352-4642(26)00069-6.
Fracture Risk Remains High and Largely Unaddressed After Kidney Transplantation
Kidney transplant recipients had a 21% 10-year fracture risk, unchanged over two decades. Twenty-eight percent of those with a fracture sustained another fracture, with the highest incidence at 6-12 months. Only 10% received anti-osteoporosis therapy and 17% underwent DXA within 1 year, highlighting an unmet need for post-fracture risk assessment and intervention.
KEY FINDINGS: Kidney transplant recipients continue to experience substantial fracture risk, with approximately one in five developing a fracture within 10 years after transplantation. Fracture rates remained largely unchanged over two decades, and an initial fracture was followed by a particularly high risk of another fracture. The limited use of anti-osteoporosis therapy and DXA assessment after fracture highlights an important gap in post-transplant bone health management.
BACKGROUND: Kidney transplant recipients remain at increased risk of fractures compared with the general population. However, the magnitude of this risk in the current transplant era and the likelihood of subsequent fractures after an initial event have not been fully characterized. This study evaluated post-transplant fracture risk and prognosis over two decades.
DETAILS: This retrospective cohort study included all adults who underwent a first single-organ kidney transplant between 2000 and 2022 in Denmark. Nationwide health registries provided demographic, diagnostic, procedural, prescription, transplantation, and mortality data. The study assessed cumulative incidence of first and subsequent fractures, with death treated as a competing risk, and examined fracture incidence across different transplant periods.
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The cohort comprised 3977 kidney transplant recipients, with a median age of 50 (40, 60) years; 1487 (37%) were female. Before transplantation, 503 (13%) had a history of any fracture and 176 (4%) had experienced a major osteoporotic fracture.
Among 3977 kidney transplant recipients, 788 experienced a post-transplant fracture. The 10-year risk of any fracture was 21% (95% confidence interval 20–23). Crude fracture incidence remained unchanged across the study period from 2000 to 2022, although age- and sex-standardized estimates showed a slight decline. Fractures occurred predominantly at peripheral skeletal sites.
Twenty-eight percent of patients who sustained a fracture experienced a subsequent fracture, with the greatest incidence occurring 6–12 months after the initial event. The 2-year cumulative incidence of any subsequent fracture was 13% (95% CI 11–16), increasing to 24% (95% CI 21–28) at 5 years.
Despite the fracture burden, only 10% of patients received anti-osteoporosis therapy within 1 year after a fracture, and 17% underwent dual-energy X-ray absorptiometry (DXA) within 1 year.
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Source: Ystrøm, I. K., Christiansen, C. F., Ivarsen, P., et al. Fracture Risk After Kidney Transplantation: Unchanged and Unaddressed: A Registry-Based Cohort Study Across Two Decades. Clinical Kidney Journa. 2026; 19(3): sfag029. Published: March, 2026. DOI: 10.1093/ckj/sfag029.
FDA Approves Engineered Viral Immunotherapy for Treatment-Resistant Advanced Melanoma
FDA approved Tudriqev, an engineered HSV-1-based viral immunotherapy, for adults with treatment-resistant advanced melanoma. The therapy produced tumor responses in 24.2% of patients with a median response duration of 14.1 months. Ongoing Phase III evaluation will further assess long-term efficacy and safety.
KEY FINDINGS: FDA approval of Tudriqev introduces an engineered viral immunotherapy option for adults with treatment-resistant advanced melanoma. By combining direct tumor destruction with immune activation, this therapeutic approach expands the available immunotherapy landscape for patients with limited options after progression on standard treatments. Continued evaluation through confirmatory studies will determine its long-term clinical role in melanoma management.
BACKGROUND: Patients with advanced melanoma whose disease progresses despite available systemic therapies have limited treatment options and significant unmet clinical needs. The U.S. Food and Drug Administration (FDA) approved a new engineered viral immunotherapy designed to provide a treatment option for adults with advanced melanoma that is resistant to prior therapies.
DETAILS: The FDA approved Tudriqev (vusolimogene oderparepvec, formerly RP1), an engineered oncolytic viral immunotherapy developed by Replimune, for adults with unresectable or metastatic melanoma that has progressed following treatment with an anti–PD-1 therapy and, when appropriate, targeted therapy for BRAF-mutated disease. Tudriqev is an engineered herpes simplex virus type 1 (HSV-1)-based therapy administered through intratumoral injection. The treatment is designed to selectively replicate within tumor cells, promote tumor cell destruction, and stimulate an immune response against cancer cells. The FDA approval was based on clinical evidence demonstrating tumor responses in patients with advanced melanoma who had limited therapeutic alternatives. The therapy represents an additional immunotherapeutic approach that uses direct tumor targeting combined with immune system activation. In clinical evaluation, Tudriqev demonstrated tumor reduction or elimination in 24.2% of treated patients, with a median duration of response of 14.1 months. The FDA approval provides a new treatment option for patients with advanced melanoma whose disease has become resistant to prior immunotherapy approaches. A confirmatory Phase III study is ongoing to further evaluate the therapy’s clinical benefit and long-term outcomes.
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High-Quality Donor Kidneys Frequently Allocated to Adults Despite Pediatric Priority
Among deceased-donor kidneys with KDPI-10 below 35%, 23.4% were allocated to higher-priority adults. For ideal pediatric-quality kidneys, this proportion was 34.3%, with 77.5% received by multiorgan transplant recipients. KDPI-8 is unlikely to materially change pediatric access to ideal donor kidneys.
KEY FINDINGS: Despite pediatric allocation priority, a substantial proportion of high-quality donor kidneys continues to be allocated to adults with greater priority, predominantly multiorgan transplant recipients. The revised KDPI-8 calculation is not expected to materially alter the proportion of ideal pediatric-quality kidneys prioritized for children, although it changes the clinical composition of the donor pool by increasing the proportion of HCV-seropositive donors and reducing the proportion of donors after circulatory death. These findings highlight persistent limitations of KDPI-based allocation for pediatric candidates and support continued evaluation of policies that balance equity, donor-recipient matching, and long-term transplant outcomes.
BACKGROUND: Children receive allocation priority for deceased-donor kidneys with a kidney donor profile index (KDPI) <35%, although certain adult candidates retain higher priority. The recent transition from the 10-variable KDPI (KDPI-10) to the revised 8-variable KDPI (KDPI-8), which excludes donor race and hepatitis C virus (HCV) status, raised questions regarding its potential effect on pediatric access to high-quality donor kidneys.
DETAILS: This retrospective cohort study analyzed 60,587 deceased donors and their kidney recipients recorded in the Organ Procurement and Transplantation Network registry from January 1, 2018, through December 31, 2023. The investigators compared donor characteristics and kidney allocation patterns using KDPI-10 and KDPI-8. Ideal pediatric-quality donors were defined as donors with a KDPI <35%, donation after brain death, age <35 years, creatinine <=1.5 mg/dL, and no infectious risk, diabetes, or hypertension. Among kidneys from donors with KDPI-10 <35%, 23.4% were allocated to adults in categories with greater priority than pediatric candidates. Among ideal pediatric-quality kidneys, 34.3% were allocated to these higher-priority adult recipients, and 77.5% of these transplants were received by multiorgan transplant recipients. The proportion of donors meeting ideal pediatric-quality criteria was similar with KDPI-10 and KDPI-8 calculations (32.7% vs 33.5%). However, the KDPI-8 group included more Black donors (15.3% vs 9.9%) and HCV-seropositive donors (11.1% vs 3.6%) and fewer donors after circulatory death (12.7% vs 20.3%).
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Source: Sonnenberg, E. M., Amaral, S., Zhang, S., et al. Allocation of Kidney Allografts From Donors With Kidney Donor Profile Index <35% and the Impact of Kidney Donor Profile Index Revisions on Access to Transplantation for Children. American Journal of Kidney Diseases. 2026; Published: August 22, 2026. DOI: 10.1053/j.ajkd.2026.02.643.
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