BACKGROUND:The clinical utility of [18F]-fluorodeoxyglucose positron emission tomography in well-differentiated pancreatic neuroendocrine tumors remains unclear. While its prognostic role is established in high-grade disease, its value in grade 1 and grade 2 pancreatic neuroendocrine tumors, particularly in guiding systemic therapy, requires further evaluation. METHODS:We retrospectively analyzed 140 consecutive patients with histologically confirmed grade 1 (n = 44, 31.4%) or grade 2 (n = 96, 68.6%) pancreatic neuroendocrine tumors (per the 2022 World Health Organization Classification of Tumors, Fifth Edition) who underwent baseline dual-tracer positron emission tomography/computed tomography (68Ga-DOTA-(Tyr3)-octreotate and [18F]-fluorodeoxyglucose) between 2018 and 2023 at a tertiary cancer center. The cohort represents 15.6% of all gastroenteropancreatic neuroendocrine tumors evaluated during the study period and was selected for dual-tracer imaging based on predefined clinical indications. Primary end points were overall survival and progression-free survival. RESULTS:[18F]-Fluorodeoxyglucose avidity was observed in 97 of 140 patients (69.3%), with significantly higher prevalence in grade 2 tumors (73/96, 76.0%) compared with grade 1 (24/44, 54.5%; χ2 = 5.58; P = .018). On multivariate analysis, [18F]-fluorodeoxyglucose avidity (hazard ratio, 9.74; P = .026) and skeletal metastases (22/140, 15.7%; hazard ratio, 3.62; P = .002) were independently associated with inferior overall survival. In grade 1 pancreatic neuroendocrine tumors, [18F]-fluorodeoxyglucose avidity did not influence prognosis, with 5-year overall survival of 90.7% and progression-free survival of 67.1% irrespective of [18F]-fluorodeoxyglucose uptake. In contrast, grade 2 [18F]-fluorodeoxyglucose-avid tumors (n = 73) demonstrated significantly worse outcomes compared with [18F]-fluorodeoxyglucose-negative counterparts (n = 23), with 5-year overall survival 61.5% versus not reached (P = .003) and median progression-free survival 41.2 months ([18F]-fluorodeoxyglucose avid) versus 94.8 months ([18F]-fluorodeoxyglucose negative); P = .006. Systemic chemotherapy (52/140, 37.1%) did not improve survival in [18F]-fluorodeoxyglucose-avid patients. Completion of ≥4 peptide receptor radionuclide therapy cycles (22/73, 30.1%) was associated with improved survival (5-year overall survival 72.6% vs 40.6%; P = .020); landmark analysis confirmed a directional progression-free survival benefit. CONCLUSION:[18F]-Fluorodeoxyglucose avidity is prognostically significant in grade 2 well-differentiated pancreatic neuroendocrine tumors but was not associated with improved outcomes following systemic chemotherapy in this retrospective cohort. In grade 1 tumors, [18F]-fluorodeoxyglucose avidity had no prognostic or therapeutic consequence. These findings support the prognostic rather than predictive role of [18F]-fluorodeoxyglucose positron emission tomography and requires prospective validation.
BACKGROUND:The substantial increase in the use of donation after circulatory death livers enabled by normothermic machine perfusion, along with associated improvements in post-transplant outcomes, has raised important questions regarding the contemporary role of living donor liver transplantation. METHODS:Using Scientific Registry of Transplant Recipients data from January 2021 to August 2024, we compared real-world outcomes of living donor liver transplantation versus donation after circulatory death liver transplantation with and without normothermic machine perfusion and whether these outcomes differed across recipient-, donor-, and center-level subgroups. Death-censored graft and overall patient survival were evaluated using Kaplan-Meier methods and multivariable Cox proportional hazards models adjusted for clinically relevant covariates. RESULTS:Among 6,105 adult recipients, 42.9% underwent donation after circulatory death without normothermic machine perfusion, 28.4% donation after circulatory death with normothermic machine perfusion, and 28.7% living donor liver transplantation. Over time, donation after circulatory death normothermic machine perfusion use expanded broadly across states with increasing adoption at multiple centers, whereas living donor liver transplantation activity remained concentrated in a limited number of high-volume regions and showed minimal growth nationally. Compared with donation after circulatory death transplantation with normothermic machine perfusion, donation after circulatory death transplantation without normothermic machine perfusion was associated with a higher adjusted hazard of graft failure (adjusted hazard ratio, 1.88; 95% confidence interval, 1.25-2.84; P = .0025), whereas living donor liver transplantation was not associated with a statistically significant difference in graft failure (adjusted hazard ratio, 0.82; 95% confidence interval, 0.48-1.41; P = .4814). Adjusted mortality did not differ significantly for either donation after circulatory death without normothermic machine perfusion (adjusted hazard ratio, 1.06; 95% confidence interval, 0.80-1.42; P = .6708) or living donor liver transplantation (adjusted hazard ratio, 0.96; 95% confidence interval, 0.69-1.33; P = .8169) compared with donation after circulatory death with normothermic machine perfusion. CONCLUSION:Donation after circulatory death with normothermic machine perfusion and living donor liver transplantation were not associated with statistically significant differences in adjusted graft failure or mortality, although these findings do not establish equivalence. Living donor liver transplantation was associated with lower unadjusted graft-loss hazards in shorter recipients and selected center-volume subgroups, supporting individualized graft selection.
Rural settings can be challenging with regard to the level of resources and general support of surgery. Effective advocacy is the means to deal with barriers to good surgical care. While advocating for more support for rural health care can appear daunting, it can be accomplished. This article gives concrete examples of tools for rural surgeons to participate in strong advocacy as well as success stories. This article can serve as a primer to begin or amplify a surgeon's advocacy journey.
Significant research has occurred over the last 2 decades outlining the disparities that female residents and residents who are underrepresented in medicine face. While there is an increasing number of institutional protocols and initiatives published in the literature attempting to improve these disparities, enrollment and retention of minority residents remain lower than expected. Designing and implementing measures to improve the recruitment, retention, and daily experience of women and underrepresented in medicine residents involves significant challenges because of the complex nature of the disparities that these residents experience. We describe our own experience with The Pregnancy Curriculum, an initiative that created sweeping culture changes and initially disruptive policies in our own institution to support pregnant residents. As we reflect on our own experience, we find that honoring the individuality of residents and their unique goals creates sustainable and effective changes to support residents. Herein, we outline the disparities residents face, current research in institutional protocols, and our own response to the challenges that residents experience.
BACKGROUND:Leadership can be succinctly defined as influencing behavior to achieve desired results. Physicians influence the behavior of patients, team members, and colleagues many times each day to achieve desired outcomes, yet leadership is rarely framed or taught as a core clinical competency. In practice, physicians routinely lead patients through complex decisions, guide interprofessional teams, support families during times of uncertainty, and model professional behavior for trainees. METHODS:This article reframes physician leadership as an essential function of clinical care and presents a practical, longitudinal framework for leadership development across the medical profession. A concentric circles model describes leadership growth across four interdependent domains: leading self, leading another, leading teams, and leading organizations. Complementing this individual framework, four institutional lines of effort are proposed: developing interest, providing foundational education, refining leadership through apprenticeship, mentorship, and coaching, and building a pipeline of future leaders. RESULTS:The proposed framework provides a scalable approach for embedding leadership development across medical education, clinical practice, and health care systems. Recognizing leadership as a core clinical competency aligns with existing accreditation standards and creates a unifying framework for strengthening communication, professionalism, teamwork, and systems-based practice. The model also links individual leadership development with institutional strategies that can support progressive growth across the continuum of a physician's career. CONCLUSION:Leadership is an essential component of everyday clinical practice rather than a competency reserved for physicians in formal administrative roles. It is a fact that all physicians are leading every day; the question is whether we recognize it and train for it. Integrating structured leadership development throughout medical training and professional practice represents a meaningful opportunity to strengthen physician effectiveness, enhance team performance, and improve patient outcomes.
