BACKGROUND:This is the third updated enhanced recovery after surgery (ERAS®) society guideline presenting a consensus for optimal perioperative care in gynecologic oncology surgery. METHODS:A database search of publications using Embase and PubMed was performed (2018-2025). Studies for key elements within the ERAS gynecologic oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the grading of recommendations, assessment, development and evaluation (GRADE) system. RESULTS:All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS:The updated evidence base and recommendation for items within the ERAS gynecologic oncology perioperative care pathway are presented by the ERAS® society in this consensus review. Gynecologic surgeons may consider incorporating these recommendations into perioperative pathway design, with efforts to achieve consensus within their practice where feasible.

BACKGROUND With the increasing use of large language model (LLM) chatbots in healthcare, evaluating their ability to provide reliable and understandable information in multiple languages is critical, particularly in fields such as anesthesia, where patient education is essential. The study primarily aimed to compare the quality of ChatGPT 4.0's and DeepSeek V3's English responses, with secondary aims to evaluate content and communication differences between English and Turkish responses. MATERIAL AND METHODS Anesthesiologists proficient in both languages were recruited as experts. Ten frequently asked questions in anesthesia were selected and translated for evaluation. Responses from ChatGPT 4.0 and DeepSeek V3 in both English and Turkish were assessed for overall quality and content quality (accuracy, comprehensiveness, and safety) and communication quality (understanding, empathy/tone, and ethics), and Turkish and English responses were compared by the evaluators. RESULTS Eleven experts evaluated the responses. English responses of ChatGPT 4.0 were superior to the English responses of DeepSeek V3 in overall (P<0.001). English responses of ChatGPT 4.0 were superior to the Turkish responses in the terms of overall, content, and communication quality (P<0.001 each) and English responses of DeepSeek V3 were superior to the Turkish responses in the terms of overall (P<0.001), content (P<0.001) and communication (P=0.001) quality. CONCLUSIONS ChatGPT 4.0 performed better than DeepSeek V3 in the English language in terms of overall quality of responses to 10 frequently asked questions in the field of anesthesia and the English responses provided by ChatGPT 4.0 and DeepSeek V3 outperformed the Turkish responses.

Background:Chronic pain after caesarean delivery is associated with impaired maternal quality of life, yet validated risk assessment tools are lacking. We evaluated a novel symptom-based SPACE (Sleep, Pain, Affect, Cognition, Energy)-Postpartum framework, conceptualised as a multidomain symptom system through triangulation of qualitative interviews, prospective cohort observations, and prior literature, for predicting chronic pain at 3 months postpartum. Methods:In this prospective observational cohort study in participants undergoing caesarean delivery, psychosocial variables and the SPACE-Postpartum framework were evaluated via validated self-report questionnaires, including a single-item measure assessing perceived control, at 24-48 h, 2 weeks, and 3 months postpartum. Chronic pain was defined as pain persisting at 3 months. A five-item model, selecting one measure for each SPACE domain, was derived using ridge-regularised logistic regression. Latent class and mediation analyses explored clustering and pathways. Results:A total of 143 participants were enrolled between February and September 2024, with 70% remaining at the 3-month follow-up time point and 40% (40/100) reporting chronic pain. The SPACE-Postpartum framework, incorporating inpatient perceived control interference (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.00-1.28; P=0.055), 2-week average pain intensity (OR, 1.43; 95% CI, 1.09-1.92; P=0.013), activity interference (OR, 1.24; 95% CI, 1.03-1.51; P=0.028), sleep disturbance (OR, 1.08; 95% CI, 1.01-1.15; P=0.029), and depressive symptoms, demonstrated moderate discrimination for predicting chronic pain (apparent area under the curve [AUC], 0.76; 95% CI, 0.67-0.85), with optimism-corrected AUC 0.71 and close-to-ideal calibration. A high-burden early latent profile (Sleep, Pain, Cognition) was associated with greater pain interference at 3 months (β=0.88, 95% CI, 0.12-1.64; P=0.024). Mediation analysis suggested acute pain had direct effects, while sleep disturbance was an independent risk marker for subsequent chronic pain. Conclusions:We report that chronic pain after caesarean delivery is common. Early multidomain assessment may enable risk stratification and facilitate targeted intervention. The SPACE-Postpartum framework provides early proof-of-concept for a structured system of interacting symptom domains to support risk stratification, warranting multicentre validation.

Large language models (LLMs) are used in all areas of life and have become one of the information sources for those seeking healthcare. Although ChatGPT is the most well-known, Claude, CoPilot, and GEMINI are also among the other LLMs. Some of these models have been studied in terms of their response quality metrics to frequently asked questions (FAQs) about broad content areas like anesthesia and to specific FAQs related to obstetric analgesia. However, no studies have yet been conducted on questions related to nerve blocks. In this study, we evaluated the quality of the answers given by the four LLMs to frequently asked questions related to ‘nerve block’. Prospective, Delphi study, Survey. Ten FAQs were identified and presented to four LLMs. A Delphi study was conducted to develop an assessment tool. A survey study was then conducted using the developed tool, in which the evaluators, selected through a thorough process, evaluated the LLM responses. The quality of LLM responses was assessed by raters using the ARQuAT (Assessing Response Quality in AI Texts) tool, determined through Delphi rounds. Evaluation criteria included content criteria such as accuracy, comprehensiveness, security, timeliness, and relevance, as well as communication criteria such as understandability, empathy, ethical considerations, readability, and neutrality. ChatGPT and Claude demonstrated superior performance in ARQuAT-Overall scores compared to GEMINI and CoPilot (p < 0.001). ChatGPT and Claude achieved satisfaction rates above 80

Abstract Introduction Poor sleep in the postpartum period is linked to adverse maternal and infant outcomes. However, the prevalence of insomnia disorder in this population remains unclear with estimates ranging from 1.3% to 59.6%(Sultan 2022, Sivertsen 2015). We aimed to determine the prevalence of insomnia disorder and characterize sleep (sleep disturbance (SD) and sleep-related impairment (SRI)) at 6 weeks postpartum. Methods Following IRB approval, patients were recruited in a longitudinal prospective cohort study evaluating newly adapted postpartum PROMIS-SD and SRI surveys. Adults who had delivered a live infant via any delivery mode were approached during delivery admission at two US hospitals (CA and AR) and invited to complete three surveys (Bergen Insomnia Scale(BIS),PROMIS-SD and SRI) at 6 weeks postpartum. Participants were also invited to complete virtual 1 hour structured clinical interviews diagnostic for sleep disorders(SCISD-R, the criterion standard for diagnosing sleep disorders), at 6 weeks postpartum until 150 interviews were completed. Demographic, clinical, and neonatal variables were collected. Primary outcome was prevalence of insomnia disorder based on SIDSD-R. Secondary outcomes were sleep characteristics (sleep satisfaction, quality, duration, latency, awakenings) and survey scores. Descriptive statistics were used to report findings. Results 150 of 413 invited patients (36.3%) completed SCISD-R at 44±7 days postpartum. Among the interviewees, 68 had spontaneous vaginal, 7 operative vaginal, 43 planned and 30 unplanned caesarean deliveries. Mean age was 33±5 years. Through SCISD-R, insomnia disorder was diagnosed in 20 (13%) participants, but only two had received any clinical evaluation for insomnia. Among the 144 surveys completed, median BIS was 20[IQR 14-27], PROMIS-SD T score was 51[IQR 45-56], and SRI T score was 57[IQR 50-62], suggesting normal SD and mild SRI in most participants. “Poor” or “very poor” sleep quality was reported by 29%(43/150), and 51%(74/144) reported they were “not at all” or only “a little” satisfied with their sleep. 85% (129/150) patients reported sleeping < 7 hours a night. Sleep latency ≥30 minutes was reported in 20%(30/150), and 84% (126/150) reported waking 1-4 times nightly. Conclusion Insomnia disorder prevalence at 6 weeks postpartum was 13% using SCISD-R. Most cases were undiagnosed. Improved identification of insomnia disorder in the postpartum period is necessary. Support (if any)

Background:The molecular mechanisms governing adaptive neuroprotection during the postpartum period remain unknown. We hypothesized that circulating exosomes contain bioactive cargo (such as Hsp20) that confer neuroprotection against ischemic injury during the postpartum period. Methods:Exosomes were isolated from plasma of postpartum female mice (ppExos) and control female mice, and from serial blood samples obtained from healthy human volunteers during pregnancy (3rd trimester) and again on postpartum day 2. Exosomal size and protein markers were confirmed via nanoparticle tracking analysis and Western blotting. Neuroprotection with exosome treatment was assessed in vitro using mouse neuronal and astrocyte cultures and human retinal pigment cell line subjected to simulated ischemia. In vivo neuroprotection was assessed using transient middle cerebral artery occlusion (MCAO) in young adult and aged mice. Mitochondrial integrity and reactive oxygen species (ROS) production were evaluated by live cell imaging. In vivo neuroprotection was evaluated by assessing infarct volume and neurobehavioral scores. Changes in mitochondrial dynamics were measured by immunofluorescence and Western blot. Human exosomes were sent for proteomic assessment (SomaScan™) followed by differential expression analysis (R software v4). Protein quantification was validated by immunoblot. Results:ppExos significantly reduced infarct volumes and improved neurological deficits post-MCAO in both young and aged female mice. In vitro, ppExos reduced ROS generation in all cell types after simulated ischemia and reduced mitochondrial fragmentation in astrocytes. Mitochondrial fusion proteins Mfn2 and Opa1 proteins were elevated in maternal postpartum brains, and preserved in both astrocyte and neuronal cell cultures after in vitro ischemia with ppExo treatment. Proteomics revealed significant upregulation of heat shock protein 20 (Hsp20) in human ppExos, while Western blot validated elevated Hsp20 in both human and mouse ppExos. Simulated ischemia significantly reduced Hsp20 in astrocyte and neuronal cultures which was reversed by treatment with ppExos. In conclusion, ppExos represent a previously unrecognized, naturally optimized neuroprotective agent that enhances mitochondrial resilience and antioxidant defenses associated with enhanced Hsp20 expression. These findings establish a novel platform for sex-informed, cell-free therapies in ischemic cerebrovascular accidents.

To estimate the prevalence of insomnia disorder and insomnia symptoms, explore risk factors for insomnia disorder, and characterize sleep at 6 weeks postpartum. Following IRB approval, adults who delivered a live infant at two academic US hospitals were prospectively recruited with a pre-specified cross-sectional analysis planned at 6 weeks postpartum, evaluating new sleep disturbance (SD) and sleep-related impairment (SRI) surveys. Participants were invited to complete surveys (Bergen Insomnia Scale (BIS), PROMIS SD, and SRI), and a structured clinical interview for sleep disorders (SCISD-R, the diagnostic standard), at 6 weeks postpartum, until 150 interviews were completed. Demographic and clinical variables were collected. Primary outcome was prevalence of insomnia disorder by SCISD-R; secondary outcomes were sleep characteristics and survey scores, clinical and sociodemographic factors associated with insomnia disorder, and exploratory evaluation of the diagnostic accuracy of BIS, PROMIS SD, and SRI for insomnia disorder identified by SCISD-R. Associations were assessed using univariate odds ratios and 95

Postpartum sleep is a unique construct, and existing sleep patient-reported outcome measures (PROMs) do not adequately address some of its fundamental domains. We aimed to develop postpartum-specific extension items to the PROMIS Sleep Disturbance (SD) and Sleep Related Impairment (SRI) item banks. The postpartum-specific SD and SRI items were developed to add to the existing PROMIS SD and SRI item banks. Postpartum-specific PROMIS items were generated based on findings from literature characterizing postpartum sleep, including systematic reviews and qualitative interviews with patients and experts from diverse specialties. The candidate items were subsequently iteratively adapted and selected through a modified Delphi process involving a panel of 21 stakeholders including experts in obstetrics, sleep, psychiatry, patients and partner representatives. Items achieving consensus with ≥ 70

OBJECTIVE:The primary objective of this study was to estimate the prevalence of new-onset anxiety diagnoses in the postpartum period. We also aimed to estimate the prevalence of psychiatric comorbidities, explore changes by year, and identify risk factors for new-onset postpartum anxiety. METHODS:This retrospective cohort study used the Merative™ MarketScan ® Commercial Database and included adult women with commercial insurance who were at least 18 years of age, delivered a singleton or multiple gestation between 2008 and 2021, and did not have a preexisting or prepregnancy diagnosis of depression, anxiety, or posttraumatic stress disorder (PTSD). The primary outcome was a new-onset anxiety diagnosis, based on International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes, during the postpartum period (up to 12 months after childbirth). Secondary outcomes were comorbid anxiety with depression and PTSD. We also estimated the prevalence of each psychiatric condition by year and identified risk factors associated with postpartum anxiety. Univariable and multivariable regression models were constructed to identify risk factors. RESULTS:From the 1,469,121 individuals identified without prenatal mental health disorders, 84,984 individuals (5.8%; 95% CI, 5.7-5.8%) were diagnosed with new-onset postpartum anxiety within 12 months of childbirth, with 9,490 diagnosed in the first month and 75,494 diagnosed between 1 month and 1 year postpartum. Comorbid anxiety and depression occurred in 18.0 per 1,000 individuals in the study cohort (95% CI, 17.8-18.2), and comorbid anxiety and PTSD occurred in 0.9 per 1,000 individuals (95% CI, 0.9-1.0). The prevalence of postpartum anxiety increased from 30.8 per 1,000 individuals in 2008 to 122.9 per 1,000 individuals in 2021 ( P for trend<.001). Independent risk factors for new-onset postpartum anxiety diagnosed 1-12 months postpartum included younger age, North Central U.S. residence, earlier gestational age at delivery, cesarean delivery, antenatal or early postpartum sleep disorders, severe maternal morbidity (including transfusion), neglected medical conditions, and neonatal complications. CONCLUSION:Postpartum anxiety was estimated to affect nearly 6% of patients with commercial insurance in the United States and has increased fourfold since 2008. Risk factors associated with postpartum anxiety may help to identify at-risk individuals who could benefit from early intervention.

Abstract Introduction Peripartum sleep disorders are linked to adverse maternal health outcomes and impaired infant bonding. Although higher incidences of sleep disorders have been reported during the peripartum period, risk factors for new postpartum sleep disorders remain under explored. We aimed to identify risk factors associated with new sleep disorders in the first year following childbirth. Methods We conducted a retrospective cohort analysis of a US commercial insurance claims database(MerativeTM Marketscan® Research Database). Women aged 18–55 with continuous insurance coverage from 90 days before estimated last menstrual period to 1 year after delivery were included. Exclusions were fetal demise, unknown delivery mode, and preexisting sleep disorders 3 months before delivery. Primary outcome was to identify demographic, medical, obstetric, and infant variables associated with new sleep disorder diagnoses between 1 and 12 months postpartum. Secondary outcomes included incidence of insomnia, sleep-related breathing disorders(SRBD) and sleep-related movement disorders(SRMD), and the monthly incidence of sleep disorders in the first year postpartum. Descriptive statistics were used and associations were assessed using univariate odds ratios and 95% confidence intervals (CIs), and multivariable logistic regression analysis was performed to identify independent predictors. Results 1,534,840 patients from 2007-2022 (vaginal delivery 68.5%; cesarean delivery: 31.6%) were included. Mean maternal age at delivery was 31.6±4.6 years; mean gestational age 38.4±2 weeks. Medical risk factors for new sleep disorders were major mental health disorder (adjusted odds ratios (aOR) 2.98, 95%CI [2.88, 3.09]), delivery BMI >40 (aOR 2.08, [1.95, 2.23]), substance use disorder (aOR 1.79 [1.65, 1.94]) and maternal age ≥35 (aOR 1.67 [1.29, 2.16]) (p< 0.001). Obstetric factors associated with sleep disorder diagnoses included pre-eclampsia(aOR 1.33 [1.26, 1.39]), severe maternal morbidity(aOR 1.25 [1.14, 1.37)), neglected maternal morbidity (aOR 1.22 [1.18, 1.26]), caesarean delivery(aOR 1.16 [1.12, 1.20]), and gestational age < 32 weeks(aOR 1.12 [1.07, 1.16]) (p < 0.001). Incidences of insomnia, SRBD, and SRMD were 0.77%, 0.12%, and 0.09%, respectively in the first year postpartum. Monthly incidences increased by 34% from months 1 to 6 postpartum (1,393 to 1,867 cases per month). Conclusion We identify clinical and obstetric risk factors for new postpartum sleep disorders. Screening these high-risk groups may facilitate timely referral and treatment. Support (if any)

OBJECTIVE:To evaluate the association between mode of delivery and incidence of new postpartum maternal psychiatric conditions in a national obstetric cohort. METHODS:This was an observational cohort study of individuals with singleton live births in the United States (2008-2022) identified from the Merative™ MarketScan® Commercial Database using International Classification of Diseases, Ninth or Tenth Revision, Clinical Modification codes. Individuals with a psychiatric diagnosis preceding delivery and those with preterm births before 37 weeks of gestation were excluded. The exposure was mode of delivery, categorized as 1) spontaneous vaginal, 2) successful operative vaginal delivery (OVD), 3) planned cesarean, 4) unplanned cesarean without OVD attempt, 5) and unplanned cesarean after failed OVD attempt. The primary outcome was a new diagnosis of depression, anxiety, posttraumatic stress, or other serious psychiatric condition or a new antidepressant prescription within 6 months postpartum. Multivariable Poisson regression models with robust SEs estimated associations between mode of delivery and postpartum psychiatric conditions, first for any psychiatric condition and then separately by each condition. RESULTS:Of 934,524 included births, 66% were spontaneous vaginal, 4% were successful OVD, 14% were planned cesareans, 15% were unplanned cesareans without OVD attempt, and 1% were unplanned cesareans after failed OVD attempt. Compared with spontaneous vaginal births, postpartum psychiatric conditions were higher after planned cesarean births (11.4% vs 9.2%, adjusted risk ratio [RR] 1.19, 95% CI, 1.17-1.21), unplanned cesarean births without OVD (10.8% vs 9.2%, adjusted RR 1.16, 95% CI, 1.14-1.18), and unplanned cesarean births with failed OVD (10.9% vs 9.2%, adjusted RR 1.26, 95% CI, 1.18-1.35). Postpartum psychiatric condition risks were similar between individuals with spontaneous vaginal births and those with successful OVDs (9.2% vs 9.2%, adjusted RR 1.00, 95% CI, 0.97-1.03). CONCLUSION:Postpartum psychiatric conditions were increased after cesarean deliveries, planned or unplanned, but not after successful OVDs. Results suggest that cesarean delivery may be associated with an increased risk of psychiatric conditions and warrants closer surveillance postpartum.