Cureus最新文献

{"title":"Nonattainability of the Fragility Index.","authors":"Thomas F Heston","doi":"10.7759/cureus.108357","DOIUrl":"https://doi.org/10.7759/cureus.108357","url":null,"abstract":"<p><strong>Background: </strong>The fragility index (FI) is intended to quantify how many outcome changes would be required to convert a statistically significant two-arm trial result into a nonsignificant one. A reliable statistical metric should produce a result for every valid case it evaluates. This study examined whether a fragility value is always attainable for every statistically significant trial result.</p><p><strong>Methods: </strong>FI was analyzed as follows: baseline significance was required (p < 0.05), one-way movement only, and outcome changes were restricted to converting a nonevent to an event in the arm with fewer events, while keeping the arm size fixed. Nonattainability was assessed by determining whether valid 2×2 tables exist for which no finite FI can be obtained under these rules. Evidence is provided through formal counterexamples, complete enumeration of all valid nondegenerate 2 × 2 tables up to total sample size N = 60, and empirical evaluation of published two-arm trials with binary outcomes.</p><p><strong>Results: </strong>Valid baseline-significant 2 × 2 tables exist for which FI is not attainable. A simple counterexample is {3,0,4,11}: baseline two-sided Fisher's exact p = 0.0429, the arm with fewer events is uniquely identified, but that arm has no nonevents available for the required toggle; thus, no legal FI path exists. Enumeration revealed that unattainable cases first appeared at N = 18 and then recurred at every larger sample size through N = 60; by N = 60, a total of 2,390 of 20,774 evaluable baseline-significant tables were unattainable (11.5%). In an empirical dataset of published trials, 2 of 82 baseline-significant evaluable trials (2.4%) were not attainable.</p><p><strong>Conclusions: </strong>The FI is not universally attainable. This is a structural property of the FI algorithm, confirmed by mathematical proof, a complete table enumeration, and published trial data.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108357"},"PeriodicalIF":1.3,"publicationDate":"2026-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13148188/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cost-Trajectory Framework for Total Episode Expenditure in Complex Wound Reconstruction: The CASCADE (Cost Analysis of Surgical Complications and Downstream Expenditure) Model.","authors":"Andrew M Klapper, Anthony N Dardano, Michael Risin, Karla Maita","doi":"10.7759/cureus.108363","DOIUrl":"https://doi.org/10.7759/cureus.108363","url":null,"abstract":"<p><p>Complex wound reconstruction may progress through stage-dependent clinical and economic trajectories in which wound failure leads to infection, reoperation, prolonged hospitalization, post-acute care, outpatient wound management, and possible readmission. Procedural-cost evaluation may not fully capture these downstream consequences in high-risk reconstructive settings. This paper presents the CASCADE (Cost Analysis of Surgical Complications and Downstream Expenditure) model, a conceptual, literature-derived decision framework rather than a primary data analysis or statistically validated predictive model. CASCADE applies an expected-value framework to evaluate the reconstructive strategy at the index operation, using three bounded inputs: failure probability (P), failure trajectory cost (C), and incremental reconstruction cost (ΔC). These inputs are structured into the decision rule ΔC < ΔP × C. A Clinical Risk Score (CRS) is used to standardize the assignment of cases into risk tiers. Across illustrative high-risk wound environments, failure trajectories may increase total episode expenditure from approximately $80,000-$150,000 after successful reconstruction to $400,000-$1,000,000+ after failure-driven care. These values are literature-informed illustrative estimates used to parameterize the framework, not observed case-level measurements. Sensitivity analysis demonstrates that at CRS ≥6, the CASCADE decision threshold often exceeds typical incremental reconstructive procedure costs across plausible input combinations. CASCADE provides a reproducible, bidirectional framework for trajectory-based cost evaluation in complex wound reconstruction. It may support surgical decision-making, institutional planning, and reimbursement analysis when total episode cost, rather than index procedural cost alone, is the appropriate unit of economic evaluation. The framework evaluates cost relationships but does not define reimbursement levels and requires future validation against institutional or claims-based datasets.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108363"},"PeriodicalIF":1.3,"publicationDate":"2026-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13148454/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of Intra-operative Contamination of an Anterior Cruciate Ligament Reconstruction Graft: A Cross-Sectional Survey of UK Orthopaedic Surgeons.","authors":"Hassan Kazemi, Josh Henry, Jack A Turnbull, Neil Jain","doi":"10.7759/cureus.108309","DOIUrl":"https://doi.org/10.7759/cureus.108309","url":null,"abstract":"<p><p>Purpose Intra-operative anterior cruciate ligament (ACL) graft contamination is a rare but recognised complication. There are no guidelines or consensus on the management of this occurrence. Our aim was to survey trauma and orthopaedic surgeons with a knee subspecialty interest in the United Kingdom (UK) who perform ACL reconstruction (ACLR) to explore the preferred strategy when there is intra-operative graft contamination. Methods An online questionnaire was sent to UK ACLR surgeons. The survey included the year of training completion, the average number of ACLs per year, whether they have experienced any intra-operative graft contamination, the strategies implemented, and whether they are aware of any literature and how it has influenced their strategies. Results Twenty-eight responses were received, with an average of 11 years of experience in ACLR, totalling an estimated of more than 15,000 ACLR. Three surgeons surveyed had experienced a single intra-operative ACL graft contamination, all of which were soaked in chlorhexidine gluconate (CG) solution. Of those surgeons who had not encountered a contaminated graft, 11 (44%) would use CG, 7 (28%) would soak in saline and vancomycin solution, and 7 (28%) would harvest a new graft. Conclusions There is significant variation in management strategy for an intra-operative contaminated graft in ACLR. This variation highlights the need for further work to develop a consensus for guidance for ACLR surgeons.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108309"},"PeriodicalIF":1.3,"publicationDate":"2026-05-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13143141/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847740","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Collision Sports: The Need for Further Education in Rugby.","authors":"Thomas J Papadimos, Brent Altenhof, Ravindera Uberoi, Justin P Reinert","doi":"10.7759/cureus.108322","DOIUrl":"https://doi.org/10.7759/cureus.108322","url":null,"abstract":"<p><p>Rugby is a collision sport and the fastest growing sport in the United States. Nonsteroidal anti-inflammatory drugs (NSAIDs), which can be acquired without prescription, are used by millions of individuals daily. Athletes in collision sports such as rugby overuse them, and the management of these analgesic anti-inflammatory drugs is gaining importance to healthcare providers in sports because of their potential organ toxicities. Athletes, amateur and elite, may misconstrue the perceived advantages of NSAIDs and seem to be unaware of the serious complications arising from their overuse. This overuse of NSAIDs by athletes should cause heightened health concerns to players, coaches, and physicians when athletes are administered or self-administer these drugs. Key educational messages include avoidance of prophylactic and prolonged unsupervised use of NSAIDs, understand the risks of analgesic masking, make proper return-to-play decisions, and related organ toxicities. More education and awareness regarding NSAIDs and their side effects are needed.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108322"},"PeriodicalIF":1.3,"publicationDate":"2026-05-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13148564/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847676","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Novel Neurofibromatosis Type 1 (NF1) Frameshift Mutation Associated With Atypical Hypotensive Pheochromocytoma: A Case Report.","authors":"Rojda Kotan, Ensar Gazi Göçer, Mehmet Sait Koç","doi":"10.7759/cureus.108246","DOIUrl":"https://doi.org/10.7759/cureus.108246","url":null,"abstract":"<p><p>Neurofibromatosis type 1 (NF1) is an autosomal dominant tumor predisposition syndrome associated with an increased risk of pheochromocytoma. Pheochromocytoma typically presents with hypertension and catecholamine excess; however, atypical clinical features may occur. A 58-year-old Turkish male patient with clinically diagnosed NF1 was evaluated for persistent hypotension (approximately 90/50 mmHg) without classic catecholamine-related symptoms. Biochemical testing showed isolated elevation of plasma and urinary metanephrine, while normetanephrine and other catecholamines were within reference ranges. Imaging revealed a 3.7 cm left adrenal mass with increased uptake on Gallium-68 DOTA-octreotate Positron Emission Tomography/Computed Tomography (Ga-68 DOTATATE PET/CT). The patient underwent left adrenalectomy after carefully titrated preoperative alpha-blockade due to baseline hypotension. Histopathological findings were consistent with pheochromocytoma. Genetic analysis using next-generation sequencing identified a heterozygous NF1 frameshift variant (c.3322dup p.(Thr1108AsnfsTer9)), predicted to result in a premature termination codon and classified as pathogenic according to American College of Medical Genetics and Genomics (ACMG) / Association for Molecular Pathology (AMP) criteria. Postoperatively, metanephrine levels normalized and blood pressure remained stable. Pheochromocytoma in patients with NF1 may present with hypotension and isolated biochemical abnormalities. This possibility should be considered in the appropriate clinical context. The identified NF1 variant contributes to the existing literature on NF1-associated tumors.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108246"},"PeriodicalIF":1.3,"publicationDate":"2026-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13142198/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Extensive Cutaneous and Scalp Metastases From Hormone Receptor-Positive Breast Cancer Successfully Treated With CDK4/6 Inhibitor Therapy: A Case Report.","authors":"Ricardo Fernández-Ferreira, Verónica Bautista-Piña, Mireya Barragán-Dessavre, Georgina Cruz-Morales, Jesús Montaño-Hernández, Alejandro Salas-Pérez, Rosa María Vicuña-González, Rosa Anaya-Jiménez, Regina Moreno-López, Sandra-María García-López, Isabel-Alicia Loya-Aguilar","doi":"10.7759/cureus.108234","DOIUrl":"https://doi.org/10.7759/cureus.108234","url":null,"abstract":"<p><p>Cutaneous metastases from breast cancer (CMBC), including those involving the scalp, are typically observed in advanced stages of the disease and are relatively uncommon, particularly in hormone receptor-positive subtypes. We present the case of a 68-year-old woman with breast cancer metastatic to the skin, characterized by multiple firm, hyperpigmented, painless nodules distributed over the body, including the scalp. The patient has been treated with a CDK4/6 inhibitor (ribociclib) in combination with endocrine therapy (ET) (letrozole) since April 2024. During follow-up, all subcutaneous nodular lesions showed significant regression. By April 2026, skin color had returned to normal in most previously affected areas, and the majority of nodules had resolved. The scalp lesion completely disappeared, with full hair regrowth at the affected site. Treatment of CMBC with CDK4/6 inhibitor-based therapy has been scarcely reported, with most cases describing ET alone. This case highlights the potential role of CDK4/6 inhibitors and documents a notable response in the scalp, skin, and subcutaneous tissue, which has not been widely described.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108234"},"PeriodicalIF":1.3,"publicationDate":"2026-05-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13138088/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847664","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Shoulder Surgery Under Regional Anesthesia With Sedation Without General Anesthesia: A Case Series.","authors":"Gabriel José Redondano Oliveira, Daphne Nicoletti, Adriano Marchetto","doi":"10.7759/cureus.108190","DOIUrl":"https://doi.org/10.7759/cureus.108190","url":null,"abstract":"<p><strong>Introduction: </strong>In Brazil, shoulder surgeries are traditionally performed under general anesthesia combined with regional blocks. This study aimed to describe the feasibility and safety profile of regional anesthesia with sedation, without general anesthesia, for shoulder surgery.</p><p><strong>Materials and methods: </strong>Following approval by the institutional ethics committee, 10 consecutive patients undergoing elective shoulder surgery (arthroscopy, n = 6; arthroplasty, n = 4) received an ultrasound-guided superior trunk block of the brachial plexus combined with an intermediate superficial cervical plexus block using ropivacaine. The primary outcome was the conversion rate to general anesthesia. Secondary outcomes included intraoperative hemodynamic stability, pain scores, post-anesthesia recovery time, length of hospital stay, patient satisfaction (net promoter score, NPS), and complications within 14 days.</p><p><strong>Results: </strong>All blocks were successfully performed (100%). No patient required conversion to general anesthesia (0%). Intraoperative hypotension occurred in 30% of cases and was more frequent in arthroplasty procedures (50%) than in arthroscopy procedures (16.7%). The mean post-anesthesia care unit stay was 51 ± 10 minutes. Seventy percent of patients were discharged on the same day (83.3% of arthroscopy patients and 50% of arthroplasty patients). Only one patient (10%) required rescue opioid (tramadol) within the first 24 hours. Two patients experienced transient hoarseness, which resolved completely within nine hours. No cases of Horner syndrome, persistent neurological symptoms at 24 hours, 7 days, or 14 days, readmissions, or reoperations within 30 days were observed. The NPS was 10 in all patients.</p><p><strong>Conclusions: </strong>Regional anesthesia alone using a superior trunk block combined with a superficial cervical plexus block is feasible and safe for shoulder surgery without the need for conversion to general anesthesia. These preliminary findings support the potential for practice change in Brazil; however, larger studies are needed to confirm these results.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108190"},"PeriodicalIF":1.3,"publicationDate":"2026-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13135808/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847670","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Recurrent Abdominal Pain in a Premenarchal Girl: A Missed Diagnosis of Hematocolpos Identified by Point-of-Care Ultrasound.","authors":"Omar Al Awni, Sohail S Alshahrani","doi":"10.7759/cureus.108169","DOIUrl":"https://doi.org/10.7759/cureus.108169","url":null,"abstract":"<p><p>Hematocolpos is a rare but clinically significant cause of abdominal pain in peripubertal females and may be misdiagnosed as more common conditions such as constipation. We report a case of a girl aged 10 years and 10 months with multiple emergency department visits for recurrent abdominal pain, initially attributed to constipation with unremarkable prior imaging. She presented again with persistent symptoms and no history of menarche despite signs of puberty. Physical examination revealed findings suggestive of hematocolpos. Point-of-care ultrasound (POCUS) demonstrated a distended uterus, which was confirmed on formal ultrasonography. The patient was diagnosed with hematocolpos, likely secondary to an imperforate hymen, and underwent hymenectomy with a good outcome. This case highlights the importance of considering gynecologic etiologies in peripubertal females with abdominal pain and the utility of POCUS in early diagnosis.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108169"},"PeriodicalIF":1.3,"publicationDate":"2026-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13135715/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847720","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An Uncommon Site for a Common Tumor: Pleomorphic Adenoma of the Accessory Parotid Gland.","authors":"Praneeth V Tenneti, A Ravi, Leena Joseph","doi":"10.7759/cureus.108170","DOIUrl":"https://doi.org/10.7759/cureus.108170","url":null,"abstract":"<p><p>Tumors of the accessory parotid gland are rare and often misdiagnosed because of their anterior location and proximity to the facial nerve. We report a case of pleomorphic adenoma arising from the accessory parotid gland in a middle-aged man presenting with a mid-cheek swelling for 20 years. Magnetic resonance imaging demonstrated a well-circumscribed lesion along Stensen's duct. Complete surgical excision was achieved with preservation of facial nerve function. Awareness of this uncommon entity and appropriate surgical planning are essential to ensure optimal outcomes.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108170"},"PeriodicalIF":1.3,"publicationDate":"2026-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13135739/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847661","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Analyzing Trends in the Incidence of Trauma and Mechanisms of Injury Before, During, and After COVID-19 Lockdown in a Staten Island Level 1 Trauma Center.","authors":"Dorian A Bogdanovski, Vladimir Rubinshteyn, Tara Harrington, Johnathon LeBaron, Douglas Cohen, Paul S Issack, Aditi Basu","doi":"10.7759/cureus.108172","DOIUrl":"https://doi.org/10.7759/cureus.108172","url":null,"abstract":"<p><p>Background The COVID-19 pandemic has impacted every branch of medical care. Our level 1 trauma center reported a decrease in the incidence of trauma during the initial months of the pandemic. In this follow-up study, we compared the incidence of trauma in our trauma center during the COVID-19 lockdown in New York City to both pre- and post-lockdown periods. Methodology A retrospective review was conducted among all adult patients who presented to the Emergency Department at Richmond University Medical Center in Staten Island, from 2019 through 2023. Data were stratified by time, with strata being pre-lockdown, lockdown (March 2020 through June 2021), and post-lockdown. Mechanism of injury was categorized as either falls, non-fall accidents, traffic-related injuries, including pedestrians and cyclists, and all assaults, including gunshot wounds and stab wounds. Data were also categorized by trauma activation level (partial activation, full activation, consultation, or no activation). Analysis of variance was performed to compare the monthly average of the incidence of trauma during these time periods. Results With this more complete data, it was determined that while there was no difference in these time periods in the overall incidence of trauma, there was a significant difference in the incidence of assaults, stabbings, and gunshot wounds, with a significant increase in gunshot wounds during the lockdown period, along with a significant decrease in the incidence of these mechanisms in the post-lockdown period. Conclusions While previous data show an overall decrease in the incidence of trauma activations in the early days of the pandemic, this study shows a change in the pattern of mechanisms of injury. Our trauma center may expect and prepare for additional assaults and penetrating injuries during a future epidemic, leading to city-wide lockdown.</p>","PeriodicalId":93960,"journal":{"name":"Cureus","volume":"18 5","pages":"e108172"},"PeriodicalIF":1.3,"publicationDate":"2026-05-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13135737/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147847651","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}