In this position statement, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) highlights the evaluation of ring-augmented procedures in Metabolic Bariatric Surgery (MBS). A GRADE-based systematic review and meta-analysis were conducted to assess their effectiveness and safety. The analysis included 28 studies with 6939 patients. The findings demonstrated that ring augmentation in bariatric procedures may provide superior or comparable weight loss outcomes compared to standard procedures, although results were heterogenous and evidence quality varied. Ring-related complications and removal rates were generally low. While further high-quality, long-term studies are needed, current evidence cautiously supports selective use of ring augmentation in both primary and revisional MBS, particularly for Roux-en-Y Gastric Bypass (raRYGB).
Importance:Inguinal hernia repair (IHR) is one of the most commonly performed operations in the United States, with approximately 800 000 performed each year. US veterans are a unique group that is predominantly male and tends to have higher rates of medical comorbidities and tobacco use, common risk factors for hernia development. With significant advancements in IHR technique in recent years, the majority of national database studies have focused on civilian populations. Objective:To examine trends and the evolution of IHR within the Veterans Health Administration (VHA) over the past 20 years. Design, Setting, and Participants:This cohort study examined national data retrospectively from all VHA institutions in the period 2002 to 2022. Participants were veterans who received IHR within the VHA were identified through the Corporate Data Warehouse using procedure and diagnosis codes. Data were analyzed from January to April 2025. Exposure:Inguinal hernia repair. Main Outcomes and Measures:Surgical volumes and trends in IHR surgical approach across the VHA were examined over time. Additional measures included procedural urgency and surgical setting. Results:A total of 308 876 veterans underwent IHR from 2002 to 2022. Patients were predominantly male (306 905 [99.4%]; 1971 female patients [0.6%]), with a median (IQR) age of 65 (57-73) years. They had high rates of hypertension (198 792 [64.4%]), depression (102 880 [33.3%]), chronic obstructive pulmonary disease (82 608 [26.7%]) and alcohol use disorder (68 427 [22.2%]). A total of 60 088 patients (19.5%) underwent minimally invasive (MIS) IHR while 246 403 procedures (79.8%) were open. Most were outpatient (300 400 [97.3%]); only 17 352 (5.6%) were urgent or emergent. Compared with men, women were more likely to undergo MIS-IHR (452 women [22.9%] vs 59 636 men [19.4%]) and urgent/emergent procedures (218 women [11.1%] vs 17 134 men [5.6%]). Annual IHR volume increased from 12 086 in 2002 to 17 897 in 2022, with an increase in MIS-IHR from 1102 (9.2%) to 7286 (41.0%). After a decline during COVID-19, IHR numbers have since recovered and surpassed pre-2020 volume. Throughout the study period, IHRs performed in the community were more likely to be urgent or emergent cases (1015 [28.1%] vs 16 337 [5.4%] in Veterans Affairs [VA] facilities). Conclusions and Relevance:This study found that over the past 20 years, the volume of IHRs performed in the VHA system has increased, along with MIS approaches. Hernia repairs are a significant surgical burden within the veteran population, reflecting the evolving surgical practices and needs of this unique demographic.
While randomization justifies the use of unadjusted effect estimators in randomized trials, there is growing interest in covariate adjustment to improve precision. Adjusting for baseline variables that are prognostic of the outcome can reduce estimator variance, resulting in narrower confidence intervals and increased statistical power. Recent guidance by the U.S. Food and Drug Administration supports fixed adjustment for prognostic covariates using parametric regression models. However, this guidance does not address more flexible approaches using data-adaptive or machine learning methods. We offer our perspectives on covariate adjustment to improve analytic precision. We focus on estimating the average effect for the target population in trials with minimal outcome missingness. We provide a non-technical overview of effect estimators that are unadjusted and effect estimators using fixed versus data-adaptive adjustment. We offer practical suggestions for conducting adjusted analyses that are data-adaptive, fully pre-specified, transparently and reproducibly implemented, robust to model misspecification, and guaranteed to improve precision relative to unadjusted analyses — all while preserving statistical validity and the causal effect of interest. We hope that sharing our perspectives will foster broader discussion and eventual acceptance of principled, pre-specified, data-adaptive covariate adjustment in randomized trials.
Abstract Background Requests for oocyte cryopreservation for social and medical fertility preservation have increased globally. In some Arab societies, virginal women may decline transvaginal oocyte collection (TVOC) for personal or cultural reasons, which may limit access to fertility preservation. Transabdominal oocyte collection (TAOC) represents a potential alternative; however, concerns remain regarding its feasibility and effect on oocyte yield. This study evaluated the outcomes of TAOC using a vaginal ultrasound probe in virginal women. Materials and methods This retrospective cohort-control study was conducted at a tertiary fertility centre in Jordan. Outcomes of ultrasound-guided TAOC using a vaginal probe in virginal women undergoing fertility preservation (Study Group, n = 39) were compared with two control groups undergoing TVOC: Control Group I consisted of non-virginal women undergoing fertility preservation (n = 47), and Control Group II consisted of infertile women undergoing ICSI (n = 60) matched for age and AMH. The primary outcomes were the total number of oocytes and the number of mature (MII) oocytes collected. Results The mean (± SD) number of oocytes collected was 7.2 ± 5.2 in the Study Group, 8.2 ± 4.5 in Control Group I, and 7.8 ± 5.3 in Control Group II (P = 0.5). Corresponding values for mature oocytes were 6.1 ± 4.4, 6.8 ± 3.5, and 6.1 ± 4.2, respectively (P = 0.6). No complications were recorded in any group. Conclusion In this cohort, no statistically significant difference was detected in the number of total or mature oocytes collected between TAOC using a vaginal ultrasound probe and the standard transvaginal route. TAOC was technically feasible, but the study design, sample size, and limited outcome measures do not permit conclusions of equivalence.
To examine the clinical presentation, risk factors, and management strategies of shoulder injury related to vaccine administration (SIRVA) following COVID-19 vaccination. A cross-sectional study was undertaken in Northern Jordan from May 2021 to May 2022. Adults with new-onset shoulder symptoms post-COVID-19 vaccination were included. Demographic, clinical, and vaccination-related data were collected via medical records and a structured survey. Symptom characteristics, severity, duration, and treatment modalities were analysed. Sixtythree participants were enrolled. Pain at the injection site (46.0%) and limited range of motion (46.0%) were most commonly reported. Overall, 84.2% experienced moderate to severe symptoms, and 34.9% noted symptoms persisting beyond one month. AstraZeneca recipients reported higher rates of adverse events than those receiving Pfizer or Sinopharm. Conservative management, involving analgesics (44.4%) and physical therapy (42.9%), was prevalent, whereas invasive interventions were rarely necessary. Notably, 87.3% of participants expressed reluctance to receive future vaccines. SIRVA after COVID-19 vaccination can present with prolonged moderate to severe symptoms and substantial vaccine hesitancy. Emphasising proper injection technique, enhanced provider training, and early intervention is crucial to reducing the burden of SIRVA and maintaining public trust in vaccination.
