Enhanced Recovery Protocols May Improve Outcomes After Pediatric Gastrointestinal Surgery When Adherence Is High
In the ENRICH-US trial of 597 children and adolescents undergoing gastrointestinal surgery, implementing an enhanced recovery protocol did not significantly reduce overall hospital length of stay. However, patients who received at least 13 protocol elements had stays that were 1.14 days shorter and lower odds of postoperative complications. The findings underscore the importance of consistent protocol adherence when translating enhanced recovery strategies into better surgical outcomes.
KEY FINDINGS: The ENRICH-US trial did not demonstrate a significant overall reduction in length of stay from introducing a multifaceted implementation strategy. However, patients receiving a greater number of protocol elements experienced shorter hospital stays and fewer complications. These findings emphasize that the clinical benefit of enhanced recovery pathways may depend on consistent delivery of their components, not simply on adopting a protocol. Hospitals implementing pediatric ERPs should therefore monitor adherence alongside clinical outcomes and address organizational barriers that limit reliable implementation.
BACKGROUND: Enhanced recovery protocols (ERPs) combine evidence-based perioperative practices to support recovery, reduce opioid exposure, and minimize complications after surgery. Although these protocols are well established in adult surgical care, their implementation in pediatric populations has been slower. The ENRICH-US trial evaluated whether a structured implementation strategy could improve adherence to a pediatric gastrointestinal surgery ERP and enhance clinical outcomes.
DETAILS: This prospective, stepped-wedge cluster-randomized implementation-effectiveness trial included 597 patients aged 10-18 years undergoing elective gastrointestinal surgery at 18 US sites between September 2019 and June 2024. The protocol included 21 perioperative elements, supported by a structured implementation toolkit, multidisciplinary learning sessions, adherence feedback, and implementation reports. Outcomes were assessed during baseline usual care, implementation, and sustainability phases. The primary clinical outcome was postoperative hospital length of stay (LOS). Secondary outcomes included time to resumption of a regular diet, inpatient opioid use, postoperative complications, opioid prescriptions at discharge, 30-day readmission, and patient-reported health-related quality of life.
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Inflammatory bowel disease was the most common surgical indication, accounting for 433 patients (72.5%). Across the three study phases, the implementation strategy did not significantly reduce overall hospital LOS or produce significant differences in most secondary outcomes. However, patients resumed a regular diet sooner and had lower opioid use during hospitalization as the protocol progressed. A patient-level analysis demonstrated the importance of adherence. Patients who received at least 13 ERP elements had a median hospital stay that was 1.14 days shorter (95% CI, -2.01 to -0.27) and lower odds of postoperative complications (adjusted odds ratio, 0.48; 95% CI, 0.28-0.82) than patients with lower adherence. The median number of protocol elements delivered increased from 11 during baseline to 14 during both implementation and sustainability phases (P < .001).
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Source: Raval, M. V., Tian, Y., Schäfer, W., et al. Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial. JAMA Surgery. 2026; 161(7): 670-680. Published: October, 2026. DOI: 10.1001/jamasurg.2026.1382.
Timing of Vascular Access Creation in Older Adults With ESKD
A prospective European cohort of older adults with ESKD found that only 32% of AVFs were created within the defined 6-month window before hemodialysis initiation, while 42% were created early and 26% late. The findings highlight the difficulty of predicting dialysis timing and the need for better tools to individualize vascular access planning.
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.
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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.
Overdiagnosis of Papillary Thyroid Cancer in the United States
A US simulation study estimated that 72% to 94% of papillary thyroid cancer cases diagnosed between 1991 and 2019 were overdiagnosed. Reducing ultrasonography for nonpalpable thyroid nodules was modeled to substantially lower PTC incidence, with less than a 0.1% change in overall mortality. The findings highlight the potential role of reducing unnecessary imaging and diagnosis while recognizing that the estimates are model-based.
KEY FINDINGS: The findings indicate that PTC overdiagnosis remained substantial even after accounting for a possible underlying increase in true disease incidence. The modeling suggests that limiting unnecessary ultrasonography referrals for nonpalpable thyroid nodules could reduce detection of cancers unlikely to affect population mortality, potentially reducing unnecessary diagnoses and treatment-related burdens without a meaningful modeled increase in overall mortality. Because these findings are based on a simulation model rather than observed outcomes from an intervention, they should be interpreted as population-level estimates rather than evidence that reducing imaging is appropriate for individual patients.
BACKGROUND: Papillary thyroid cancer (PTC) incidence in the United States has increased substantially over recent decades, largely driven by detection of small, early-stage tumors, while population-level mortality has remained relatively stable. This pattern has raised concern that some thyroid cancers detected through imaging may never have become clinically significant. This study used a validated simulation model to estimate the extent of PTC overdiagnosis in the United States and examine the potential effects of reducing thyroid ultrasonography for nonpalpable thyroid nodules.
DETAILS: Researchers used the Papillary Thyroid Carcinoma Microsimulation Model (PATCAM) to evaluate PTC incidence among US adults aged 18 years or older from 1991 through 2019. The model accounted for changes in underlying thyroid cancer risk and estimated the proportion and absolute number of PTC cases considered overdiagnosed, defined in the model as cancers whose detection and treatment did not affect population mortality. The investigators also modeled the potential effects of reducing thyroid ultrasonography referrals for nonpalpable thyroid nodules.
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Between 1991 and 2019, the model estimated that 72% to 94% of diagnosed PTC cases were overdiagnosed. The estimated proportion was 75% to 95% among women and 63% to 90% among men. The corresponding absolute rate of overdiagnosis was 13 to 17 per 100,000 women and 3 to 5 per 100,000 men, translating to an estimated 443,212 to 573,705 women and 107,804 to 154,504 men overdiagnosed with PTC during the 28-year period. The model further estimated that reducing thyroid ultrasonography for nonpalpable nodules by 33% would reduce PTC incidence in 2019 by 17%, from 18 to 15 per 100,000 individuals. A 67% reduction in ultrasonography was associated with a modeled 41% reduction in incidence, from 18 to 11 per 100,000. In both scenarios, the modeled change in overall mortality was less than 0.1%.
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Source: Francis, D. O., Davies, L., Zhang, Y., et al. Overdiagnosis of Papillary Thyroid Cancer. JAMA Network Open. 2026; 9(2): e2559852. Published: February 24, 2026. DOI: 10.1001/jamanetworkopen.2025.59852
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.
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