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  • Charting a Strategic Path Forward Amidst Regional Health Challenges

    Charting a Strategic Path Forward Amidst Regional Health Challenges

    This year’s meeting held in a hybrid format from 7 to 9 July in New Delhi, India witnessed diverse participation from across the region and beyond. The meeting brought together over 70 participants, including national immunization programme representatives from nine countries in the WHO South-East Asia Region, immunization focal points from WHO and UNICEF headquarters, regional and country offices, the Chairperson of the South-East Asia Regional Immunization Technical Advisory Group, and key partners such as  Gavi, the Vaccine Alliance, International Federation of Red Cross and Red Crescent Societies, Coalition for Epidemic Preparedness Innovations, Department of Foreign Affairs and Trade of the Australian Government, and World Bank.

    Established in 2007, the RWG serves as the primary regional forum for partner coordination, technical collaboration, and strategic planning in immunization in the WHO South-East Asia Region. This year’s meeting focused on reviewing progress towards the Regional Vaccine Implementation Plan (RVIP) 2022–2026, addressing persistent immunization gaps, the recently evolving funding constraints aligning with Gavi’s new Strategy 6.0.

    The WHO Regional Director Ms Saima Wazed, emphasized in her opening remarks, delivered by the Director of Programme Management Dr Thaksaphon Thamarangsi, the RWG’s pivotal role in advancing immunization programmes across the South-East Asia Region over the past two decades. The Regional Director, in her message, acknowledged the region’s immunization successes but underscored ongoing challenges, including unvaccinated children, the impact of the COVID-19 pandemic, and a dynamic donor landscape. She outlined eight strategic priorities to sustain hard-earned gains, ranging from health system integration and cost-saving vaccine strategies to domestic resource mobilization and community engagement.

    Key highlights:

    • Regional progress and gaps: While the region has made significant achievements in expanding vaccine access and introducing new vaccines, major challenges persist. The number of zero-dose children rose to 2.72 million in 2023, and several countries reported large and disruptive measles outbreaks.
    • UNICEF contributions: UNICEF highlighted its work in immunization demand generation, gender-responsive programming, digital health, and sustainable financing. Behavioral insight studies, digital tools, and community engagement models were showcased as key enablers of vaccine uptake.
    • Gavi 6.0 Strategy: Gavi’s new strategy emphasizes equity, sustainability, and innovation, aiming to protect 500 million children and avert 8–9 million deaths by 2030. However, a funding gap of $2.9 billion remains, prompting a recalibration of priorities and optimization of immunization programmes and support mechanisms.
    • Country presentations: Delegates from Bangladesh, Bhutan, the Democratic People’s Republic of Korea, India, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste shared updates on national immunization strategies, challenges, and support needs. Common themes included funding constraints, vaccine hesitancy, digital transformation, and the need for stronger surveillance systems.
    • Updated RWG terms of reference (TORs): A closed-door session reviewed and adopted evolved RWG ToRs to enhance partner coordination, engage new partners, advocacy, and strategic alignment in light of funding uncertainties and shifting donor priorities
    • Looking ahead: The RWG has outlined a consolidated workplan to accelerate progress toward regional immunization goals, prioritizing and optimizing immunization and disease surveillance programmes, strengthening health systems, enhancing cross-border collaboration, and conducting joint high-level advocacy for increased domestic and donor financing.

    This meeting marks a pivotal moment for immunization programmes in the WHO South-East Asia Region. Despite ongoing challenges, all partners stand united in their commitment to protecting every mother and child through equitable and resilient immunization systems.

    2025 Annual Meeting of South-East Asia Regional Working Group on Immunization

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  • Music meets nature in Surrey care home study

    Music meets nature in Surrey care home study

    Mark Norman

    BBC South East Health Correspondent

    Mark Norman BBC Stuart Wood stands next to a set of tubular bells with a pond behind him while holding two chime hammers.Mark Norman BBC

    Stuart Wood said by studying music-making outdoors he hoped to support the wellbeing of older people.

    A care home has appointed a ‘Musician-in-Residence’ in a pioneering study exploring how outdoor music-making can benefit older people and those with dementia.

    Residents at the Huntington & Langham Estate in Hindhead, Surrey, enjoy outdoor activities from music scholar Stuart Wood as part of the pilot.

    The project examines how music and nature together can boost wellbeing, social connection, and emotional expression in care settings.

    Mr Wood said he hoped to understand how playing music outdoors “can foster social connection, emotional expression, and overall health in later life.”

    The NHS says music in a care setting can help “reduce anxiety and depression, help maintain speech and language, is helpful at the end of life, enhances quality of life and has a positive impact on carers”.

    It is also acknowledged that spending time outdoors can have a positive impact on the cognitive, emotional, and physical wellbeing of older people.

    Mr Wood’s project explores how outdoors music can further enhance social connection, uplift mood, and support mental and physical health within care home communities.

    Mark Norman BBC A group of residents play tubular bells in a garden, some in wheelchairsMark Norman BBC

    A Surrey care home said it is curious about the possibilities and the benefits of combining music and nature

    The study will form part of his Visiting Research Fellowship at Bath Spa University’s School of Music and Performing Arts.

    He will also share insights from this project with music students and post-graduate researchers.

    Mr Wood said: “What we don’t know is what happens when you bring together playing percussion and doing that outdoors, so this project is asking that question.”

    Sarah Chapman, the director of Huntington & Langham Estate, said she was “curious about the possibilities and the benefits of combining music and nature”.

    Findings from this week-long pilot study may inform a larger, international research project planned for later this year, with results expected to be published in 2026.

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  • From ayahuasca rituals to a birthday in the favelas: Arles photography festival takes us on a trip | Les Rencontres d’Arles

    From ayahuasca rituals to a birthday in the favelas: Arles photography festival takes us on a trip | Les Rencontres d’Arles

    Artists have always been fascinated with imagining the invisible – but few have taken it quite as far as Musuk Nolte. The 37-year-old Mexican photographer has spent a decade working with the Indigenous peoples of the Peruvian Amazon region – and found inspiration there by taking ayahuasca with a shaman called Julio.

    Nolte tells me he first took ayahuasca when he was five years old – with his mum, an anthropologist who studied the psychedelic brew. The powerful hallucinogenic visions he experienced while with the Shawi community in their ancestral homeland, the Paranapura basin, have been translated into a series of images titled The Belongings of the Air, presented as small suspended light boxes, glowing like fireflies in a darkened room. They are unconventional documents, not showing the Shawi directly but reflecting the Shawi cosmovision. Pulsating with flashes of bright white light, the images have an allegorical tenor: we move with quickened breath from the intimate to the epic, from a woman and child washing clothes in a river to a closeup of a man’s ear, to the blazing eyes of a big cat, to a dazzling constellation of blurry silver flecks. This latter image was created by photographing rows of candles lit for forcibly displaced relatives whose whereabouts remain unknown. The feeling it stirs is one of the universe melting.

    Dressed as a deity … Octavio Aguilar’s Tajëëw, the Snake. Photograph: Enrique Macias Martinez/Octavio Aguilar

    The Belongings of the Air is among the highlights of this year’s Les Rencontres d’Arles, the world’s oldest and most prestigious photography festival. There are dozens of exhibitions here, taking over the ancient, crumbling cloisters, churches and crypts of the Roman city until October. Nolte’s trippy, illusory work is also included in An Assembly of Sceptics, the shortlist exhibition for the 2025 Discovery award Louis Roederer Foundation that includes seven projects by artists using photography to conjure alternate versions of reality and destabilise the status quo.

    Bolivian-Algerian artist Daniel Mebarek presents portraits taken in a free mobile photo studio he set up in the huge open-air market in El Alto, Bolivia. The photographs reflect an eagerness, particularly of middle-aged men, to be seen. He recounts a story of an inebriated man who later returned to thank the photographer with a bag of pears, and another of a man who kissed his photograph in elation. There are also the fraught, time-bending, cryptic collages of Cairo by Heba Khalifa, who uses family photographs and photomontage techniques in part to help her confront and heal after an abusive childhood. The spellbinding photographs by Octavio Aguilar also travel through time to the artist’s Ayuuk ancestors, a heritage conjured through images of his friends dressed as deities important in Ayuuk mythology who influence nature. Aguilar, like Nolte, offers another way of interacting with the environment based on Indigenous knowledge and ways of seeing. As wildfires raged nearby in Marseille, less than an hour from Arles, the urgency of this message loomed large.

    An Assembly of Sceptics reflects this year’s strong Latin American focus, centred on several big exhibitions diving into the past, present and future of photography in Brazil – part of the programme of the Brazil-France cultural year.

    The story of Brazilian photography at Arles begins in São Paulo in 1939, when 18 amateur photographers founded the Foto-Cine Clube Bandeirante (FCCB). The FCCB’s headquarters in São Paulo’s first skyscraper emphasised the intertwining of photography and architecture as the vehicles of modernism. The early works of the FCCB photographers, in the 1940s and 1950s, reflected modernist ideals with a cool, graphic poise – pristine documents, sometimes verging on abstraction, of urban construction, cables, wires and the clean, curvilinear forms of São Paulo’s new modernist landmarks by the likes of Oscar Niemeyer. Human figures, when they appear, are puny against the might of progress. Later, though, several photographers started to unravel this modernist utopia, revealing those cast out, excluded from the benefits of this supposed social progress. Alice Brill was one of the rebels, who was ejected from the FCCB after less than a year. Her images move away from the exaltation of modernism to a darker picture of the human cost of development. Her photos of poverty and the poor living conditions of communities on the city’s outskirts, of cluttered streets littered with rubbish, São Paulo’s proud skyscrapers distant in the background, are a far cry from the untainted, uncrowded visions that followed the FCCB’s guidelines at the time. They act as reminders that progress rarely benefits all.

    Dazzling …. Musuk Nolte’s The Belongings of the Air. Photograph: Musuk Nolte

    At cultural space La Croisière you are propelled into the rhythm and colour of one of Brazil’s largest favelas, the sprawling Aglomerado da Serra located in the hills of Belo Horizonte. A dual exhibition, Portraitists of the Hill draws from the archives of Serra residents João Mendes and Afonso Pimenta. Mendes and Pimenta collaborated to document their local communities for more than 50 years, but this show focuses on the first two decades of their work there, between 1970 and 1990.

    Though Serra was established out of a lack of proper housing for Belo Horizonte’s swelling population, Mendes and Pimenta show the autonomy of an energetic, stylish community who they photographed with obvious affection and warmth. Here are images of irrepressible joy and happiness, beautiful and chaotic. They record the lively tempo of children’s birthday parties, the shining primary school graduates at a local state school and the agile moves of those trained in the martial art capoeira. But they also pay homage to quieter domestic moments, families in their living rooms and around kitchen tables. The exhibition pays particular attention to the duo’s images of fathers, grandfathers and men holding children – in one image, a local shopkeeper proudly holds a neighbour’s newborn baby up to the camera. A man in his underwear in his living room puts his arm around his smiling wife. A father props baby twins on his knees, a balancing act belied by his composure as he looks directly at the camera. The pictures shift ideas about the caring roles of men in a patriarchal society, as if conscious too of the legacy of these pictures, and their potential to shape how the children in them might look back and remember.

    Activist and artist Claudia Andujar, who has lived in São Paulo since 1955, is best known and widely celebrated for her work with the Yanomami Indigenous people of Amazonia. Her decades-long activism contributed to the recognition of Yanomami territory in 1992. Yet while this acclaimed work continues to be relevant given the struggles of Indigenous peoples in Brazil and beyond, it has perhaps skewed the understanding of Andujar as an artist. In the Place of the Other at Maison des Peintres redresses that, the first exhibition to home in exclusively on Andujar’s early, less known works, made in Brazil soon after she arrived in the country in the 1960s and 1970s, and before she began to work with the Yanomami.

    Cryptic collages … Heba Khalifa’s Tiger’s Eye. Photograph: Courtesy of the artist

    It’s a small but utterly enthralling show, bringing to light several series originally produced and published by Realidade (Reality), a groundbreaking Brazilian magazine published between 1966 and 1976 that combined reportage and experimental design. The images are astonishing – Andujar’s fearless, extraordinarily direct gaze is emphasised by these large-scale reproductions. For a 1967 story about the work of traditional midwife Dona Odila, Andujar captured, with an unflinching eye, the climatic moments of a child being born. These photographs of a woman labouring at home led to the magazine being confiscated by the police. Other works soar with cinematic beauty, such as a series of pictures following a controversial medium known as Zé Arigó, who was later imprisoned for his 60-second “psychic surgeries”. One excruciating image immortalises the surreal moment he inserts the flat blade of a knife into a patient’s eye.

    This exhibition draws out Andujar’s unique combination of empathy and audacity, and her deep interest in the human psyche. Her first experiments with colour filters applied to the camera evoke an apparent interest in “aura”, the things felt but not seen. Her photographs of drug addicts and of a psychodrama session take photojournalism into a daring, bold new terrain and have more in common with Dario Argento and Quentin Tarantino than Henri Cartier-Bresson and Robert Frank, who Andujar exhibited alongside at MoMA in the 1960s. The exhibition culminates in A Sônia, a series of nudes of Andujar’s one time muse, an aspiring model from Bahia. Andjuar met Sônia, and never saw her again after the three hour shoot. A Sônia presents another completely different facet to Andujar. She wasn’t happy with the original slide film portraits she took and so rephotographed them through coloured photographs – the resulting nudes look like X-rays, ethereal and strange. On the face of it this intimate exchange (and more classical subject matter) seems disconnected from Andujar’s other works – but it is ultimately about one person trying to understand another, from the outside in. Just as her photojournalism in Brazil began as a way of understanding her adopted homeland, here Andujar writes that “perhaps I was seeking an idealised reflective identification with what I do not know about my own body”.

    Ethereal … Claudia Andujar’s In the Place of the Other. Photograph: Claudia Andujar/Courtesy of the artist/Instituto Moreira Salles

    Latin America dominates, but Australia too has an important landmark moment at Arles this year – the first ever big exhibition of Australian photography to be held at the festival. On Country is an expansive, encompassing survey featuring about 20 artists in the huge Eglise Sainte-Anne. As a result of its ambition and diversity, it is varied in quality, with some repetitive moments. The exhibition centres on connections to Australian terrains and topographies, taking inspiration from the First Peoples’ definition of “country” as a broad way to describe a spiritual and cultural connection to the land. Adam Ferguson’s brooding, dramatic photographs of the Australian outback, made over the course of a decade, ruminate on the devastating impact of environmental crisis on rural life in these scorched, vast landscapes. Ying Ang’s evocative, architectonic installation, with intersecting images and vinyls, explores the overdevelopment of the Gold Coast, now Australia’s crime capital. The best works, though, were the large-scale, weirdly wonderful performances of Michael Cook, a Bidjara peoples artist who photographs himself as an alter ego, dressed in a suit, in places of colonial power, multiplied until he fills the space.

    If one show truly blew me away this year, it was the mind-boggling In Praise of Anonymous Photography. Marion and Philippe Jacquier ran the recently closed Lumière des Roses gallery, a home for the nearly 10,000 photographs they’d collected over 20 years by unknown and amateur photographers. This exhibition brings together images from the collection in various categories – there’s some of the 120 Cindy Sherman-esque self-portraits by a photographer the collectors name “Zorro”, posing with whips, aviation masks and thigh-high boots. There are Mr Roussel’s carnivalesque portraits of a wife, her features altered, sometimes grotesquely, by painting applied to the photograph. There are the pictures a Parisian pharmacist took of his customers without consent via a secret camera installed behind his counter – only one child seems to have spotted what was going on. Why the pharmacist did this, we will never know. There is also a tranche of the self-portraits of Lucette, the hero, in my mind, of Arles this year. Born in 1908, she travelled solo to France, Greece, Egypt, Syria and Scandinavia between 1954 and 1977. On her trips, she took 850 pictures – and the sole subject of them all is herself. She is also almost always out of focus. The photographs, when the Jacquiers acquired them, were meticulously organised and catalogued by date and location.

    The show is brilliant and bizarre, telling stories about obsession, fetish, loneliness and secret desire. In fact it’s so good that it sends out a warning to all professional photographers – perhaps anyone really can take a decent picture.

    Les Rencontres d’Arles runs until 5 October

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  • Four richest Africans wealthier than half the continent: Oxfam

    Four richest Africans wealthier than half the continent: Oxfam

    Aliko Dangote, Founder and Chief Executive Officer of the Dangote Group, speaks during the commissioning of Dangote Petroleum refinery in Ibeju-Lekki, Lagos, Nigeria, May 22, 2023. — Reuters

    LAGOS: The four richest Africans are wealthier than about half of the continent’s 750 million people, anti-poverty charity Oxfam said in a report published on Thursday, warning widening inequality was hampering democracy.

    Oxfam named only Nigerian billionaire Aliko Dangote, the continent’s richest man, in its report.

    But according to Forbes, the top four are rounded out by South Africans Johann Rupert and Nicky Oppenheimer, along with Egyptian businessman Nassef Sawiris.

    Over the past five years, African billionaires have seen their wealth soar by 56%, with the richest among them recording even higher gains, Oxfam said.

    Nearly half of the top 50 most unequal countries in the world are also on the continent, according to the report.

    Oxfam argued that government policies are skewed against the poor and provide leeway for the continent’s super-rich to amass even more wealth.

    “Most African countries are not fully leveraging progressive taxation to effectively tax the super-rich and address inequality,” the report said.

    However, it also blamed mounting inequality on “regressive” International Monetary Fund policies and illicit financial flows — notably the use of tax havens to hide wealth abroad.

    The NGO said that inequality is hindering democracy, hampering poverty reduction and worsening the climate crisis, with “political capture” by the wealthy undermining “pro-poor government policies and the effectiveness of public institutions”.

    For instance, in Africa’s biggest democracy, Nigeria, people seeking political office are often priced out of running by exorbitant fees demanded by political parties.

    Meanwhile vote-buying is rampant in a country where tens of millions of people are desperately poor.

    Despite the issue, Oxfam said that nearly nine-in-ten African countries since 2022 have backtracked on policies on taxation, labour rights and minimum wages which the charity says are necessary to help tackle inequality.

    Oxfam recommended an overhaul of tax administrations on the continent.

    Currently, Africa’s tax systems are nearly three times less effective at redistributing income from the richest one percent than the global average, it said.

    Additionally, the continent loses an estimated $88.6 billion annually through illicit financial flows.

    A review of the tax systems of 151 countries found that “Africa was the only region in which countries have not increased effective tax rates since 1980”, the charity said.


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  • Evaluating the Opioid-Related Adverse Events of Oliceridine Versus Con

    Evaluating the Opioid-Related Adverse Events of Oliceridine Versus Con

    Introduction

    Traditional opioids, such as morphine, fentanyl, and oxycodone, remain widely used in clinical practice for managing moderate to severe postoperative pain. However, the prevalence of opioid-related adverse events (ORADEs) poses a significant clinical challenge that necessitates urgent attention. These adverse events, which can range from mild to severe, include respiratory depression, gastrointestinal disturbances, and increased healthcare costs. Studies have shown that ORADE rates can be as high as 23.92%, with 5.9% to 6.5% of patients potentially becoming long-term opioid users following surgery.1–4 Additionally, there is a growing interest in opioid-free anesthesia due to concerns about opioid-related adverse effects.5 This highlights the need for novel opioid formulations that can effectively reduce ORADEs while maintaining analgesic efficacy.

    Oliceridine, a next-generation μ-opioid receptor agonist, has emerged as a promising candidate in this regard. Unlike traditional opioids, which activate both the G-protein-dependent and β-arrestin pathways, oliceridine selectively targets the G-protein pathway. This pathway is primarily responsible for mediating analgesia and sedation, while the β-arrestin pathway is associated with adverse effects such as respiratory depression, gastrointestinal dysfunction, and drug tolerance. By focusing on the G-protein pathway and minimizing β-arrestin activation, oliceridine acts as a biased μ-receptor agonist, potentially offering effective pain relief with a reduced risk of ORADEs.6–8

    Several clinical studies have explored the analgesic potential of oliceridine in various surgical settings, demonstrating its efficacy and improved safety profile compared to traditional opioids.9–12 However, these studies often involve limited sample sizes and controlled environments, which may not fully capture the drug’s performance in routine clinical practice. Furthermore, there is a lack of large-scale, real-world evidence to substantiate the benefits of oliceridine in reducing ORADEs across diverse patient populations.

    Postoperative pain control after thoracoscopic surgery remains a critical challenge, as inadequate analgesia compromises respiratory function, delays recovery, and increases the risk of chronic postsurgical pain. Thoracoscopic procedures, despite their minimally invasive nature, often provoke intense acute pain due to pleural irritation, intercostal nerve trauma, and chest tube placement.13,14 Traditional opioids, while effective, are limited by dose-dependent side effects such as respiratory depression, gastrointestinal disturbances, and sedation—complications that are particularly detrimental in thoracic surgery patients with preexisting cardiopulmonary vulnerabilities.

    To address this gap, our study aims to evaluate the impact of oliceridine on ORADEs in a real-world clinical setting. This research is among the first to provide a comprehensive comparative analysis of ORADEs between oliceridine and conventional opioids in PCIA. By offering valuable insights into the practical application of oliceridine, this study seeks to inform and optimize postoperative pain management strategies, ultimately enhancing patient outcomes.

    Methods

    Study Design, Setting, and Participants

    This study is a propensity score-matched, retrospective, observational, single-center cohort study conducted at Shanghai Chest Hospital. The study was approved by the Clinical Research Ethics Committee of Shanghai Chest Hospital (IS24138) and adhered to the Helsinki Declaration. The reporting of the cohort study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Due to the retrospective nature and anonymity of the data, the requirement for written informed consent was waived.

    Setting and Participants

    Electronic records of patients undergoing elective thoracoscopic-assisted lung resection and receiving PCIA from January 2024 to June 2024 were collected. Exclusion criteria included age less than 18; postoperative continuous mechanical ventilation or ICU admission with a tracheal tube; conversion to open surgery; thoracic day surgery or absence of PCIA, and inadequate postoperative follow-up information.

    Anesthesia and Analgesia Techniques

    The anesthetic management in both study groups was standardized in accordance with institutional protocols. All enrolled patients received either general anesthesia (GA) alone or GA combined with ultrasound-guided thoracic paravertebral block (TPVB). TPVB were single-shot, administered pre-incision under ultrasound guidance, injecting 20 mL of 0.5% ropivacaine at T3–T7. Anesthesia was induced with: propofol (2.0–2.5 mg/kg) or remimazolam besylate (0.3–0.4 mg/kg), sufentanil (0.4–0.6 μg/kg), rocuronium bromide (0.6–0.9 mg/kg). Double-lumen bronchial catheter or single-lumen tracheal tube with bronchial blocker was placed under adequate neuromuscular blockade and bispectral index (BIS) values maintained at 40–60. Anesthesia Maintenance: Continuous infusion of Propofol (2–6 mg/kg/h) or remimazolam besylate (1–3 mg/kg/h) titrated to maintain BIS 40–60. Remifentanil (0.05–0.15 μg/kg/min) administered via target-controlled infusion, with supplemental boluses of sufentanil (5–10 μg) and rocuronium bromide (0.1–0.2 mg/kg) as clinically indicated. All patients received sugammadex (4 mg/kg) until TOF ratio ≥0.9 in PACU. All patients received PCIA for postoperative pain management. The solution of the electronic analgesia pump was a mixture of the following agents: opioid agents, dexamethasone and/or dolasetron. The selection and dosing of opioid analgesics (sufentanil, hydromorphone, oxycodone or oliceridine) are guided by the clinical expertise of anesthesiologists. The background continuous rate was 2 mL/h, and the bolus dose was 2 mL with a 15-min lockout interval.

    Data Collection

    Data were collected retrospectively from the postoperative anesthesia follow-up database and electronic medical records. Collected data included patient demographics, clinical characteristics, analgesic and antiemetic use in PCIA, incidence and type of ORADEs, and pain scores on the first postoperative day. Opioid formulations in PCIA were converted to morphine milligram equivalent doses for comparison.15

    Outcome Variables

    ORADEs included postoperative nausea and vomiting (PONV), urinary retention, and opioid-induced respiratory depression (OIRD). PONV was defined as nausea and vomiting within 24 hours post-surgery. Urinary retention was defined as the inability to urinate requiring catheterization. OIRD was defined as oxygen saturation below 90% for more than 5 min or hypercapnia with arterial carbon dioxide tension over 50 mmHg, requiring naloxone or nalmefene.16,17

    Additional outcomes included the incidence of moderate-to-severe pain (NRS ≥4) within 24 hours postoperatively, NRS pain score, recovery time after anesthesia (from PACU admission to endotracheal tube removal), and PACU length-of-stay. Anesthesia-related complications such as allergy, reintubation within 6 hours, cardiac arrest within 24 hours, death within 24 hours, and neurological complications were also recorded.

    Sample Size

    In the ATHENA trial, oliceridine demonstrated a favorable safety profile, with common adverse reactions including nausea (31%), constipation (11%), and vomiting (10%).12 At our center, the incidence of ORADEs was approximately 30.0%, with a postoperative nausea and vomiting (PONV) incidence of 20.0%, similar to the findings by Suzuki Y et al.18

    Assuming a control event rate (CER) of 30% and a relative risk (RR) reduction of 20% with oliceridine, the incidence of ORADEs in this population would be reduced to 24% within the first 24 hours postoperatively. Based on this assumption, we estimated that a minimum of 1149 cases per group would be required to achieve 90% power, using a two-sided χ2 test to detect the primary outcome in the oliceridine group versus the traditional opioid group at a significance level of P < 0.05.

    Considering a potential 15% data loss due to incomplete or cleaned data and the estimate that approximately one-third of patients would be excluded during the propensity score matching period, we calculated that we would need to initially include at least 2028 patients per group to ensure sufficient sample size for the final analysis.

    To achieve this sample size, we retrospectively collected data from a six-month period. Given the retrospective nature of this study, the sample size was ultimately determined by the number of eligible patients available within this timeframe. We initially included 8208 patients who met the inclusion criteria. Propensity score matching was then performed to balance the covariates between the oliceridine and conventional opioid groups.

    Bias and Confounding

    Propensity scores were calculated using logistic regression models for the following covariates: demographics (age, gender, body mass index), duration of surgery, type of surgery, anesthesia-related factors (ASA classification, duration of anesthesia, type of anesthesia, morphine equivalents of analgesic medication in PCIA), and whether admission was to the ICU. Patients were matched 1:1 with their nearest neighbor based on the closest propensity score for each subject. A caliper size of 0.25 was used to avoid poor matches.

    Statistical Analysis

    Categorical data are presented as absolute numbers (percentages), while continuous data are presented as mean ± standard deviation (SD) for normally distributed variables or median with interquartile range (IQR) for non-normally distributed variables. Continuous variables were compared using a two-sample t-test for normally distributed data or a Wilcoxon rank-sum test for non-normally distributed data. In the propensity score-matched cohort, absolute standardized mean differences (SMDs) were calculated to assess the balance between groups before and after matching. An SMD value of ≤ 0.1 indicated a lack of meaningful imbalance. Relative risk (RR), 95% confidence interval (CI) and P values for postoperative outcomes were calculated for both groups after PSM. The association between each factor and ORADEs was examined using univariate logistic regression analysis. Odds ratio (OR), 95% CI and beta coefficients were calculated. Subsequently, a logistic regression analysis was performed using the stepwise selection method, with these covariates as explanatory variables and ORADEs as the outcome variable. The following four covariates were identified as explanatory variables for ORADEs: age (≥ 65 years), gender (female), body mass index (BMI) based on the Asian Adult BMI Classification, and type of anesthesia. Adjusted odds ratio (aOR), 95% CI, and beta coefficients were calculated.

    Additionally, groups were compared using a non-linear mixed model for continuous variables. We also assessed the primary outcome in prespecified subgroups to investigate the relationship between oliceridine and heterogeneous populations in a post hoc analysis. Restricted cubic splines were used to flexibly model and visualize the relationship between predicted oliceridine use and the risk of ORADEs. All P values were two-sided, and a P value < 0.05 was considered statistically significant. All analyses were performed using SPSS version 24 and R software version 4.1.2.

    Results

    Between January 2024 and June 2024, a total of 9262 patients were retrospectively screened (Figure 1). Of these, 1054 patients were excluded based on the following criteria: age <18 years; postoperative continuous mechanical ventilation or admission to ICU with tracheal tube; thoracic day surgery or without PCIA; conversion to open surgery, or inadequate postoperative follow-up information. Leaving 8208 patients who met the study selection criteria. Among these, 3171 patients received oliceridine, and 5037 patients received conventional opioids. After propensity score matching, 2803 matched pairs (5606 patients) were further analyzed. Patient demographics and the morphine equivalent doses used were comparable between the matched cohorts.

    Figure 1 Flow diagram showing the process used to select patients for inclusion in this retrospective cohort study.

    Patient characteristics and intraoperative information before and after matching are presented in Table 1. The standardized mean difference (SMD) after matching for all variables was less than 0.1, indicating that the propensity score matching was performed appropriately and resulted in balanced allocation between the two groups.

    Table 1 Baseline and Procedural Characteristics Before and After Propensity Score Matching Between Oliceridine and Conventional Groups

    This analysis confirms that the matching process effectively balanced the covariates, allowing for a valid comparison of ORADE rates between the oliceridine and conventional opioid groups.

    Postoperative Outcomes After Propensity Score Matching

    The risk of postoperative outcomes for the matched groups is summarized in Table 2. After PSM, the incidence of ORADEs was significantly lower in the oliceridine group compared to the conventional group (24.3% [681/2803] vs 27.8% [780/2803], RR 0.87, 95% CI 0.80–0.95, P < 0.01). The incidence of PONV was significantly lower in the oliceridine group (15.5% [433/2803] vs 19.7% [553/2803], RR 0.78, 95% CI 0.70–0.88, P < 0.001).

    Table 2 Postoperative Outcomes Risk in Thoracoscopic Lung Resection with Oliceridine Vs Conventional Opioids (After PSM)

    There were no significant differences between the two groups in the incidence of opioid-induced respiratory depression (OIRD) (8.6% [242/2803] vs 8.3% [233/2803], RR 1.04, 95% CI 0.87–1.23, P = 0.66), urinary retention (0.9% [51/2803] vs 0.8% [42/2803], RR 1.21, 95% CI 0.81–1.82, P = 0.35), moderate to severe pain (22.2% [621/2803] vs 21.6% [606/2803], RR 1.03, 95% CI 0.93–1.13, P = 0.63), pain scores (median NRS 2 [0, 4] for both groups, P = 0.08), PACU length-of-stay (median 60 minutes [59.3, 63.0] for oliceridine vs 60 minutes [59.3, 64.4] for conventional, P = 0.51), and recovery time (median 20 minutes [20.0, 20.1] for both groups, P = 0.98). One patient in each group was reintubated within 6 hours after surgery. No other anaesthesia-related complications occurred in either group.

    These results indicate that oliceridine is associated with a lower risk of ORADEs and PONV compared to conventional opioids, while other postoperative outcomes such as OIRD, urinary retention, pain severity, PACU length-of-stay, and recovery time show no significant differences between the two groups after PSM.

    Analysis of Risk Factors for Opioid-Related Adverse Events

    Table 3 presents the results of univariate and multivariable logistic regression analyses for the risk of ORADEs. The analyses utilized a stepwise selection method to identify significant predictors. The results indicate that age, gender, BMI, and type of anesthesia were not significantly associated with the development of ORADEs. However, the use of oliceridine was associated with a reduced risk of ORADEs compared to conventional opioids, as shown by both univariate (OR 0.83, 95% CI 0.74–0.94, P < 0.01) and multivariable analyses (OR 0.84, 95% CI 0.74–0.94, P = 0.003).

    Table 3 Univariate and Multivariable Analyses for ORADE Risk

    Detailed analyses of the risk factors for postoperative nausea and vomiting (PONV) were provided in Table S1. Notably, gender and the use of dexamethasone were significantly associated with PONV. Male gender and the addition of dexamethasone to PCIA were found to reduce the risk of PONV. The relative strengths of each risk factor for ORADEs and PONV are illustrated in Figure 2, with no significant interactions observed (P for interaction > 0.05).

    Figure 2 Intensity of ORADES and PONV risk factors. Forest plot showing adjusted ORs for ORADES and PONV after propensity score matching.The analysis included data from 5606 patients. Solid boxes indicate adjusted ORs and bars indicate 95% CIs. An adjusted OR < 1 indicates a favorable outcome for the variable. Values are expressed as adjusted OR with 95% CI.

    Abbreviations: OR, odds ratio; ORADEs, Opioid-related adverse events; PONV, postoperative nausea and vomiting.

    Visualization of Predicted Oliceridine and ORADEs Risk

    Figure 3 illustrates the relationship between predicted oliceridine dosage and the risk of ORADEs in thoracoscopic-assisted surgery using restricted cubic splines. The analysis revealed a U-shaped relationship between predicted oliceridine dosage and PONV risk. Specifically, there was a substantial reduction in risk within the lower range of predicted oliceridine dosages, with the lowest risk observed around 14 mg. Beyond this point, the risk increased (P for non-linearity < 0.05). This non-linear relationship highlights the importance of optimizing oliceridine dosage to minimize the risk of PONV.

    Figure 3 Dose-response relationship between oliceridine and ORADEs in PCIA. Restricted cubic spline analyses illustrating the non-linear association of oliceridine dose (mg) with the probability of ORADEs after thoracoscopic lung surgery. Analyses adjusted for covariates identified in propensity score matching. Dashed horizontal line indicates reference risk (odds ratio = 1). (A) Overall Opioid-related adverse events (ORADEs); (B) Postoperative nausea and vomiting (PONV); (C) Opioid-induced respiratory depression (OIRD); (D) Urinary retention.

    Discussion

    In this retrospective observational cohort study, we assessed the risk of ORADEs associated with the use of oliceridine and conventional opioids for PCIA using PSM method. Our results demonstrated that the incidence of ORADEs was significantly lower in the oliceridine group compared to the conventional opioids group (24.3% vs 27.8%). Additionally, the incidence of PONV, was significantly lower in the oliceridine group (15.5% vs 19.7%). This findings suggests that the use of oliceridine in PCIA may potentially reduce the side effect profile compared to conventional opioids. To the best of our knowledge, this is the first study to compare the incidence of ORADEs between oliceridine and conventional opioids via PCIA with sufficient certainty.

    To eliminate the potential effects of covariates on the risk of ORADEs, we calculated and balanced the morphine equivalents between the two groups by PSM. We hypothesized that the observed difference could be explained by the mechanism of oliceridine as a biased MOR agonist. Oliceridine selectively agonizes the G-protein-coupled pathway and only weakly activates the β-arrestin-2 pathway, thereby ameliorating ORADEs. Unlike the G-protein pathway, which induces analgesia, the β-arrestin pathway causes ORADEs, particularly respiratory depression and gastrointestinal complications, while diminishing analgesia.19,20 Preclinical data as early as 2013 demonstrated that TRV130 (Oliceridine) is a biased ligand with differentiated pharmacology, successfully translating evidence that analgesic and adverse MOR signaling pathways are distinct.21 Other biased opioids such as MEB-1166, MEB-1170, and PZM21 have become the current trend in the development of analgesic drugs.7,22

    Results from a Phase III study of oliceridine for postoperative analgesia after abdominoplasty showed that the 0.35 mg and 0.5 mg doses of oliceridine demonstrated a favorable safety and tolerability profile in terms of respiratory and gastrointestinal adverse effects when compared to morphine, with equivalent analgesic efficacy. This provides a new therapeutic option for the management of moderate to severe postoperative pain.11 The ATHENA study similarly showed that oliceridine provided effective postoperative analgesia. However, among the 768 patients treated with oliceridine in the trial, the incidence of adverse reactions leading to early discontinuation and serious adverse reactions were 2% and 3%, respectively. Nausea (31%), constipation (11%) and vomiting (10%) were the most common adverse reactions, with most being mild (37%) or moderate (25%).12 This findings suggest that clinicians should focus on evaluating and discussing their patients’ risk of opioid-related harm.

    OIRD and PONV are challenging, resource-intensive, and costly ORADEs. A study by Oderda GM et al analyzed 592,127 hospitalized patients and found that the incidence of respiratory depression ranged from 3% (obstetrics/gynecology) to 17% (cardiothoracic/vascular), and the incidence of nausea/vomiting ranged from 44% (obstetrics/gynecology) to 72% (general surgery/colorectal). The increased odds of OIRD after cardiothoracic surgery were associated with opioid dose.23 PONV afflict approximately 30% of patients overall, with female patients being at high-risk patients after surgery.24 In the absence of head-to-head comparative data from randomized controlled trials, an indirect treatment comparison analysis demonstrated that oliceridine was associated with a significant reduction in the incidence of nausea and/or vomiting or the need for antiemetics compared to hydromorphone in orthopedic surgeries.25 Our study further evaluated the effects of oliceridine on ORADEs in real-world thoracoscopic surgical settings. Furthermore, our study showed that oliceridine doses above 14 mg in PCIA were associated with an increased incidence of PONV.

    In our study, there were no statistical differences in the incidence of OIRD and urinary retention. OIRD is a common but often underdiagnosed cause of postoperative respiratory depression. Current methods used to identify and monitor postoperative respiratory safety events have serious limitations, and new tools and techniques are being developed that promise to improve the prediction of respiratory depression.17 The latest VOLITION study shown that nearly one quarter of patients experienced a respiratory compromise with oliceridine analgesia.26 In a pharmacokinetic-pharmacodynamic comparison, the authors quantified the effects of oliceridine and morphine on the respiratory system of elderly volunteers. High doses of oliceridine and both doses of morphine cause a rapid onset of respiratory depression, with peak effects reached 0.5 to 1 hour after taking the opioid. After reaching peak, respiratory depression caused by oliceridine returned to baseline more quickly than morphine.27 These factors may explain why the incidence of ORADEs was higher with traditional opioid than with oliceridine. This was further supported by our results based on restricted cubic spline curves, which allowed for flexibility examining in the association between oliceridine dose and the risk of ORADEs.

    In the era of the growing opioid crisis, it is even more important for clinicians to assess and discuss their patients’ risk of opioid-related harm. Although data on post-approval use of oliceridine is limited, all clinical evidence collected to date, including the results of exploratory analyses, suggest a lower incidence of opioid-related adverse events associated with oliceridine. Our studies investigating the use of oliceridine or other opioids with different pharmacological profiles for PCIA and focusing on patient outcomes in thoracoscopically assisted lung surgeries, will further add to the clinical evidence in this field.

    Limitations

    The subjects included in this study were patients undergoing thoracoscopic lung resection; therefore, the generalizability of the results may be constrained by this specific patient population. PSM improves causal inference within the study cohort, but does not inherently increase external validity. While the analgesic regimen implemented in this study comprised three integral components—loading dose, patient-controlled analgesia (PCA), and supplemental dose—the inherent limitations of retrospective studies impede our ability to fully understand the dynamic adjustments of opioids, such as oliceridine. Consequently, the analgesic efficacy of oliceridine in the context of thoracoscopic lung resection surgery requires further validation through subsequent multicenter trials with larger sample sizes.

    Secondly, in the referenced literature, the definition of OIRD also included a respiratory rate <10 breaths per minute. However, due to the limitations of the retrospective study design, data on postoperative spontaneous respiratory rates were unavailable. Given that this study relied on a retrospective analysis of electronic medical records, it was not feasible to identify and rectify potential inaccuracies within the data. This limitation underscores the need for caution when interpreting the findings and highlights the importance of prospective studies to ensure data reliability.

    Finally, although intraoperative morphine equivalent consumption was not calculated—an important factor in assessing ORADEs and postoperative pain management—this limitation was mitigated by standardized dosing protocols and propensity-matched surgery/anesthesia times between groups.

    Conclusion

    Oliceridine use in PCIA was associated with a lower incidence of ORADEs, primarily driven by reduced PONV, compared to conventional opioids. However, due to the retrospective nature of this study, these results should be interpreted with caution. Larger prospective randomized controlled trials are needed to confirm these findings.

    Data Sharing Statement

    The relevant data are available through the corresponding author on request.

    Acknowledgments

    Chengya Huang and Biying Liu are co-first authors for this study.

    Funding

    This research was supported by the Fundamental Research Funds for the Central Universities of Shanghai (YG2024LC10), National Natural Science Foundation of China (82071233) and Bei Jing Huikang Charity Foundation (RCLX2315002). The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclosure

    The authors have no conflicts of interest to disclose in this work.

    References

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    9. Dahan A, van Dam CJ, Niesters M, et al. Benefit and risk evaluation of biased μ-receptor agonist oliceridine versus morphine. Anesthesiology. 2020;133(3):559–568. doi:10.1097/ALN.0000000000003441

    10. Singla N, Minkowitz HS, Soergel DG, et al. A randomized, Phase IIb study investigating oliceridine (TRV130), a novel µ-receptor G-protein pathway selective (μ-GPS) modulator, for the management of moderate to severe acute pain following abdominoplasty. J Pain Res. 2017;10:2413–2424. doi:10.2147/JPR.S137952

    11. Singla NK, Skobieranda F, Soergel DG, et al. APOLLO-2: a randomized, placebo and active-controlled phase III study investigating oliceridine (TRV130), a G protein-biased ligand at the μ-opioid receptor, for management of moderate to severe acute pain following abdominoplasty. Pain Pract. 2019;19(7):715–731. doi:10.1111/papr.12801

    12. Sd B, Brzezinski M, Gb H, et al. ATHENA: a Phase 3, open-label study of the safety and effectiveness of oliceridine (TRV130), A G-PROTEIN SELECTIVE AGONIST AT THE µ-OPIOID RECEPTOR, IN PATIENTS WITH MODERATE TO SEVERE ACUTE PAIN REQUIRING PARENTERAL OPIOID THERApy. J Pain Res. 2019;12:3113–3126. doi:10.2147/JPR.S217563

    13. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17(6):836–844. doi:10.1016/S1470-2045(16)00173-X

    14. Joshi GP, Kehlet H. Postoperative pain management in the era of ERAS: an overview. Best Pract Res Clin Anaesth. 2019;33(3):259–267. doi:10.1016/j.bpa.2019.07.016

    15. Sutherland TN, Wunsch H, Pinto R, et al. Association of the 2016 US centers for disease control and prevention opioid prescribing guideline with changes in opioid dispensing after surgery. JAMA Network Open. 2021;4(6):e2111826. doi:10.1001/jamanetworkopen.2021.11826

    16. Apfelbaum JL, Horlocker TT, Agarkar M, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: an updated report by the American society of anesthesiologists task force on neuraxial opioids and the American society of regional anesthesia and pain medicine. Anesthesiology. 2016;124(3):535–552. doi:10.1097/ALN.0000000000000975

    17. Ayad S, Khanna AK, Iqbal SU, Singla N. Characterisation and monitoring of postoperative respiratory depression: current approaches and future considerations. Br J Anaesth. 2019;123(3):378–391. doi:10.1016/j.bja.2019.05.044

    18. Suzuki Y, Kawashima S, Makino H, Doi M, Nakajima Y. Comparison of postoperative nausea and vomiting between remimazolam and propofol: a propensity score-matched, retrospective, observational, single-center cohort study. Kor J Anesthesiol. 2023;76(2):143–151. doi:10.4097/kja.22441

    19. Azzam AAH, McDonald J, Lambert DG. Hot topics in opioid pharmacology: mixed and biased opioids. Br J Anaesth. 2019;122(6):e136–e145. doi:10.1016/j.bja.2019.03.006

    20. Hill R, Sanchez J, Lemel L, et al. Assessment of the potential of novel and classical opioids to induce respiratory depression in mice. Br J Pharmacol. 2023;180(24):3160–3174. doi:10.1111/bph.16199

    21. Sm D, Ds Y, Dh R, et al. A G protein-biased ligand at the μ-opioid receptor is potently analgesic with reduced gastrointestinal and respiratory dysfunction compared with morphine. J Pharmacol Exp Ther. 2013;344(3):708–717. doi:10.1124/jpet.112.201616

    22. Schmid CL, Kennedy NM, Ross NC, et al. Bias factor and therapeutic window correlate to predict safer opioid analgesics. Cell. 2017;171(5):1165–1175.e1113. doi:10.1016/j.cell.2017.10.035

    23. Oderda GM, Senagore AJ, Morland K, et al. Opioid-related respiratory and gastrointestinal adverse events in patients with acute postoperative pain: prevalence, predictors, and burden. J Pain Palliative Care Pharmacother. 2019;33(3–4):82–97. doi:10.1080/15360288.2019.1668902

    24. Tan HS, Dewinter G, Habib AS. The next generation of antiemetics for the management of postoperative nausea and vomiting. Best Pract Res Clin Anaesth. 2020;34(4):759–769. doi:10.1016/j.bpa.2020.11.004

    25. Biskupiak J, Oderda G, Brixner D, Wandstrat TL. Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods. J Comp Effect Res. 2024;13(5):e230041. doi:10.57264/cer-2023-0041

    26. Sessler DI, Ayad S, Bakal O, et al. Oliceridine for postoperative pain and opioid-related complications: the intravenous oliceridine and opioid-related complications (VOLITION) prospective cohort study. J Clin Anesthesia. 2025;105:111870. doi:10.1016/j.jclinane.2025.111870

    27. Simons P, van der Schrier R, van Lemmen M, et al. Respiratory effects of biased ligand oliceridine in older volunteers: a pharmacokinetic-pharmacodynamic comparison with morphine. Anesthesiology. 2023;138(3):249–263. doi:10.1097/ALN.0000000000004473

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    Does Donald Trump deserve the Nobel Peace Prize? We asked 5 experts

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  • A Qualitative Study of the Maternal Emotional and Decision-Making Expe

    A Qualitative Study of the Maternal Emotional and Decision-Making Expe

    Introduction

    In recent years, the decline of human fertility has made infertility a major problem affecting reproductive health. The development of assisted reproductive technology (ART) has provided an feasible solution for patients with infertility to achieve their fertility aspirations.1 Among them, sperm donor assisted reproductive technologies include artificial insemination with donor sperm (AID) and in vitro fertilization with donor sperm (D-IVF) and embryo transfer. This technology mainly targets men with irreversible azoospermia, severe oligospermia and genetic diseases, and achieves fertility goals by using sperm donated by human sperm banks.2 Nearly one million families in China are in need of sperm donor technology for their fertility needs.3 However, women who receive donor sperm for assisted reproduction are faced with changes in traditional kinship and psychological, ethical and social pressures caused by the nontraditional ways of conceiving such as AID and D-IVF, and often seek support and advice from their mothers.4–6 In the traditional Chinese family structure, mothers often take on the role of counsellor in their children’s reproductive decisions, and only children in particular tend to rely on their mothers for advice and emotional support.7 As a result, mothers’ emotional experiences during this critical period may have a direct impact on their daughters’ adherence to treatment and the stability of family relationships, and mothers also face psychological distress and role adjustment as their daughters go through this reproductive challenge, experiencing complex psychological changes between motherhood and grandmotherhood.8,9 Therefore, it is important to study the emotional experiences and decision-making dilemmas of mothers in ART. Most of the existing studies focus on the emotional regulation of couples using donor sperm and the ethics of sperm donation,3,5,10 but there is a lack of research on the emotional and decision-making experiences of female patients’ mother, who are the ‘invisible decision-makers’ in assisted reproduction with sperm donation. This study uses a qualitative research methodology to understand the real psychological experience and decision-making process of mothers during AID and D-IVF treatment.

    This study uses a qualitative approach to understand the real psychological experience and decision-making process of mothers during the daughter’s AID and D-IVF treatment, with the aim of providing more targeted support and assistance to health professionals, families and society.

    Methods

    Study Design

    This study was guided by the descriptive phenomenological approach in qualitative research,11 data were collected using face-to-face semi-structured interviews and reported in accordance with COREQ guidelines.12 The descriptive phenomenology adopted in this study focuses on “going back to the thing itself” and emphasizes the pure experience or “primitive intuition” of mothers whose daughter undergoes donor sperm treatment. Three interviewers had learned and mastered the content of qualitative research and interview skills. The first author, as the main interviewer, has been working in reproductive health for more than ten years and is a clinical experienced associate chief nurse. The other two interviewers were nursing graduate students and assisted in the transcription and analysis of the interview. The interviewers had no assisted reproductive technology treatment history to reduce personal bias; The interviewers participated in the care of the respondents in the diagnosis and treatment process, and established a full trust relationship with the respondents.

    Ethical Approval

    This study strictly followed the Declaration of Helsinki and was approved by the Medical Ethics Committee of Sir Run Run Shaw Hospital, Zhejiang University School of Medicine (NO.2025–0112). All respondents gave informed consent and volunteered to participate in this study. Personal information was anonymized and only members of the research team had access to the audio recordings and transcripts. Participants could withdraw at any time during the study with no consequences.

    Study Participants

    Mothers of daughters who received sperm donor assisted reproductive technology treatment at the Reproductive Medicine Center of an A-level tertiary hospital in Zhejiang Province from January 2025 to March 2025 were selected as study subjects.

    Inclusion Criteria

    a. The age ranged from 40 to 65 years;

    b. The daughter received the first assisted reproductive treatment with sperm donation;

    c. The doctor-patient communication between the daughter’s son-in-law who had participated in the treatment;

    d. The mother knew that the son-in-law was diagnosed with azoospermia before or during the treatment of the daughter, and the daughter knew and agreed to the mother’s interview with the nurses of the reproductive center.

    Exclusion Criteria

    a. Hearing, language or cognitive impairment;

    b. severe illness or inability to cooperate with the investigators

    Withdrawal Criteria

    a. The subjects asked to withdraw from the study.;

    b. The investigator considered that the subject was not suitable to continue participating in the study.

    Sampling

    A purposive sampling method was used to select subjects based on maternal age, marital status, education level, occupation, economic status, residence, and treatment plan for their daughters. The sample size was based on the principle of data saturation, that is, the interviews ended when no new themes emerged at the time of data analysis. A total of 16 potential participants were approached in this study, among whom 2 were included in the pre-interview, and 2 patients refused to join due to their unwillingness to self-disclose. Finally, 12 patients were included in this study, and the general information of the respondents is shown in Table 1. To protect the privacy of the respondents, their names were concealed and numbered M1–12 instead.

    Table 1 General Information of the Interviewees (n=12)

    Research Process

    Determining the Outline of the Interviews

    A research group was established, including 6 members, all of whom had bachelor’s degree or above, including 2 masters of nursing, and all of whom had received qualitative research training. After literature review and discussion by the research group, a preliminary interview outline was formed under the guidance of qualitative research experts. Two patients were selected for pre-interview, and the interview outline was adjusted according to the pre-interview situation, and the formal interview outline was finally formed as follows:

    a. How did you learn that your son-in-law had azoospermia? Did your daughter tell you or did she find out by accident? What were your thoughts and feelings when you found out?

    b. What do you think of sperm donation? What kind of communication have you had with your daughter and son-in-law?

    c. How do you feel about your daughter’s sperm donation?

    d. What actions would you take in the decision-making and treatment of sperm donation? How can I support my daughter in spirit or action?

    e. In the process of sperm donation and assisted pregnancy, what help and protection do you hope to get?

    Data Collection and Quality Control methods

    Mothers attending the outpatient clinic with their daughters were screened through the medical record system, and those who met the inclusion and exclusion criteria were initially contacted, the purpose of the study, the method, the principle of confidentiality and the necessity of recording were explained, and an interview was scheduled after informed consent was obtained. Three researchers with professional training and interview experience simultaneously conducted face-to-face semi-structured interviews with mothers in a warm and quiet independent clinic. The interview was scheduled with the mother in advance. During the interview, the researchers paid attention to maintaining the neutrality of language, and actively guided and encouraged the interviewees to confirm their views in time. At the same time, listen carefully, encourage respondents to express their true feelings and experiences, avoid hints, and pay attention to observe and record the non-linguistic behaviors such as the expression, speed and intonation of the respondents. The interview time was controlled within 30 to 45 minutes. After the interview, the data were checked with me, and the recording data were transcribed into text and stored in NVivo 11 software within 24 hours after confirmation.

    Data Analysis methods

    Data collection and data analysis will be conducted simultaneously. After completing an interview, the recording was transcribed into text data on the same day, and the correctness of the transcript was checked by two people. Colaizzi’s seven-step analysis method was used for data analysis.13 The specific steps were:

    a. Read all the data carefully;

    b. Extract important statements;

    c. Coding recurring concepts;

    d. The coded ideas were pooled into themes;

    e. Relate the theme to the research phenomenon and describe it completely;

    f. Induce similar ideas, sublimate the theme;

    g. Return all to the respondents for verification.

    The interview data were repeatedly read, sorted out, classified and analyzed by two research group members, and the content was presented to the greatest extent. When there was any disagreement, the research group members discussed and ruled.

    Results

    Theme 1: Emotional Complexity and Diversity When Knowing the Azoospermia of a Son-in-Law

    Participants described complex and multidimensional feelings during ART when they learned that her son-in-law needed donor sperm to have children because of azoospermia.

    Shock and Anger

    The women’s mothers, on learning of their son-in-law’s infertility, showed an inability to accept the facts. They were less accepting of this unexpected situation and resisted their daughter’s decision to use donor sperm assisted reproductive technology.

    M1:

    How is it possible! He (son-in-law) is so tall and fit, how can he have no sperm? Isn’t this harming my daughter? I have only one daughter, because he (son-in-law) can’t have a child, is it going to make my family have no more offspring?

    M3:

    Did he know (that her son-in-law had no sperm)? Is that why he divorced his ex-wife? Why didn’t he tell us before? Why should my daughter suffer like this? Leave him while she is young!

    M7:

    It was so unexpected! The couple have been married for 5 years and have told me that they are on contraception and don’t want children, and it’s actually because he (the son-in-law) can’t do it!

    M4:

    Her mother-in-law has always thought that if the young couple don’t have children, the problem must lie with my daughter, and we’ll see how her mother-in-law explains it later (with a scornful expression). All the costs of doing (donor sperm) this should be made to come out of the mother-in-law’s family!

    M11:

    My son-in-law is the one I chose for my daughter, he’s 190cm tall, fair-skinned, good-looking and has a good job, the key is that he’s a hard worker and a good basketball player, it’s really unexpected!

    Rationality and Tolerance

    When the daughter needed donor sperm for a pregnancy after learning that her son-in-law had azoospermia, some mothers showed deep care and rational thinking, especially when their daughter expressed fear of ART and was considering divorce.

    M5:

    I advise my daughter to calm down and think carefully about the good qualities of the son-in-law, he has been very considerate to you; And, while IVF can be painful, it is short-lived and finding a new partner can bring more uncertainty.

    M8 expressed her understanding and support for her son-in-law:

    My son-in-law is very filial to my husband and I. I know he loves children very much, and he feels very guilty about his lack of sperm, and my husband and I will fully support them to do so to ensure their little family is happy!

    M10:

    I believe they have thought through all aspects of the use of sperm, and I told my daughter that I will support her no matter what choice she makes.

    Secret Joy and Relief

    The mothers’ attitudes toward the use of donor sperm showed their concern for the future happiness of their daughters, their expectations for the characteristics of the ideal partner, and their deep reflection on the family education and cultural background. At the same time, they showed a potential pleasure and relief in the process of supporting of ART using the donor sperm.

    M2:

    My son-in-law is an average looking man, only 5’6”, and the small eyes in particular have always put me off. I often worry that these features will be passed on to the next generation, but I am sure the children born using donor sperm will be better looking than he is (expression full of smiles).

    M5:

    I was always worried that my son-in-law’s baldness and dry skin condition would be passed on to his children. The fact that using donor sperm will allow their children to avoid these health problems gives me peace of mind. (shows happy face)

    M6:

    The little couple were married for 7 years, always said that they did not want to have children, I urged every day, only then my daughter told me (son-in-law has no sperm). Now I’m glad to find out the cause of infertility. Only a family with children can be complete.

    M9:

    My son-in-law’s low education and limited learning ability make him suitable only for some manual work. If you choose to use someone else’s sperm, I believe the baby’s genes will be better, which will compensate for the lack of a son-in-law, and their offspring will be better.

    Theme 2: Multiple Concerns About Daughter and Her Marital Relationship

    Regarding their daughters’ choice of sperm donation technology, the mothers’ concerns mainly focused on the treatment outcome, marital stability, family structure, privacy protection and future children’s identity, which reflected their deep concern for their daughters’ future family happiness.

    Concerns About the Uncertainty of Treatment Process and Outcome

    The mother showed significant concern for her daughter’s physical health and psychological state during the process involving sperm donor treatment. They were not only concerned about the safety of the treatment, but also expressed concerns about the success rate, potential physical side effects, and their daughter’s ability to adapt to the treatment process.

    M4:

    Will the sperm donation technology cause harm to my daughter’s body? She is 37 years old and the doctors say her ovaries are not functioning well and the number of eggs is not high, does that mean the success rate is not high?

    M1:

    My daughter is very afraid of going to the hospital and has never had an injection except for preventive shots. I’ve heard that IVF requires a lot of injections, and I’m worried that she won’t be able to handle it mentally or physically.

    M3:

    My daughter may need to try many times to succeed, which will increase the financial burden, and she will not be able to work for a while. I wonder if she can bear the cost.

    M7:

    I am worried that the sperm donor technique will affect my daughter’s endocrine system as she is not normally in good health and I am not sure if she will be able to cope with the ovulation induction treatment.

    Concerns About the Risk of Privacy Breaches

    Mothers’ concerns relate to the protection of personal information, the family’s reputation and the mental health of future children. They hope to create a safe and harmonious living environment for their daughters and future children, and to avoid social pressure and potential risks caused by privacy leakage.

    M8:

    We live in a small town, everyone knows each other, once everyone knows, it will definitely be talked about, how the daughter, son-in-law and future children can stay here.

    M10:

    I am worried that if my grandchildren are ridiculed or discriminated against in school because the father is not their real father, it is unfair to the kid.

    M6:

    My son-in-law’s family business is doing very well, and if my son-in-law’s lack of sperm and my daughter’s use of a sperm donor someday became known, she would certainly face pressure and questions from the family. It would affect the prestige and future of my daughter and son-in-law in the company.

    M8:

    A large piece of land in my son-in-law’s family will be expropriated, and if my son-in-law’s brother learns in the future that the child is not related to my son-in-law by blood, I am worried that the kid will not be able to fight for the right to inherit the land in the future.

    M3:

    My neighbor’s daughter works in your hospital. Will she check the information about my daughter’s sperm donor?

    Concerns About Changes in Her Daughter’s Marriage

    The mother was worried about the impact of the daughter’s use of donor sperm on her future marriage relationship and feared that communication and understanding between the daughter and son-in-law would lead to tension or disharmony in the couple’s relationship.

    M6:

    My son-in-law doesn’t have a strong obsession with having children, but my daughter insists on having one. The child is not related to him by blood, will he accept and like the child?

    M4:

    I am afraid that if the child does not look like the father, or if the child is not naturally close to him, then the family will not be able to be as close and harmonious as in other families.

    M3:

    Sperm donor treatment is expensive and if we spend all our savings and do not succeed in getting pregnant, I am worried that her life will become more difficult and it may cause marital tension.

    M11:

    The roles of family members change after using donor sperm and I am worried that in the future my daughter and son-in-law will be at odds because of their different views on how to raise and educate their children, which in turn will affect the stability of their marriage.

    Concerns About the Identity of the Offspring

    Mothers show deep concern about the identity of the children born to their daughters using donor sperm technology, which is reflected in the legal and economic aspects of the blood relationship; and the emotional challenges that the children may face in their family and social environments.

    M6:

    If they have a child in the future but get divorced, the custody of the child should go to the woman, right? What should the we do if he refuses to pay maintenance because he is not a blood relative?

    M4:

    I am worried that the grandparents will treat the child differently when the child is born – after all, the child is not their biological grandchild and there may be prejudices.

    M11:

    If the child does not look like their parents, it will always be reminded that the child was born by sperm donation. And if the child needs a blood transfusion or something like that when they grow up, they might know their biological relationship to their parents.

    M7:

    If the couple has a bad relationship in the future, the children will suffer the most. Lay down the rules upfront, then play nice. So, in order to prevent possible future disputes, I suggest that they first consult a notary to make sure that the distribution of property and maintenance is legally protected. This will reduce disputes and protect the interests of the child.

    Theme 3: Treatment Decision-Making Interventions and Support

    In traditional Chinese culture, the concept of filial piety emphasizes family and affection, and mothers, as the core of the family, want to help their daughters make comprehensive and considered choices in major life decisions through companionship and financial support, especially in assisted reproduction processes involving fertility and family.

    Accompaniment and Economic Support

    Many mothers choose to accompany their daughters to the hospital during their assisted reproduction treatment. This accompaniment is not only a form of emotional support, but also a way of gaining information. Mothers can learn every detail of the treatment process so that they can better advise and assist their daughters.

    M6:

    I would go with her to the hospital every time to listen to the doctors and understand the treatment options. That way I would feel more comfortable and also give her encouragement and support if she hesitates.

    M10:

    I stayed in her home during this time, helping her cook, managing her diet, supervising her regular routine and trying to create a comfortable and de-stressing environment for her.

    M5:

    It’s not cheap and I’ll do everything I can to support her so that she doesn’t have to give up her fertility treatment for financial reasons.

    Support for Treatment Selection

    The role of mothers in the donor sperm treatment process is not only that of supporter, but also that of protector. They are concerned that their daughters’ personal information, medical records and reasons for choosing donor insemination may become known to others, which could affect the family’s social image and the individual’s mental health.

    M6:

    In order to ensure my daughter’s privacy, my daughter and I contacted the doctor in charge and asked about the hospital’s privacy policy and requested that the hospital not disclose any information, including to my husband, who should not know the news.

    M8:

    I reminded my daughter to dispose of information related to her hospital visits, including medical records and payment receipts, before returning to each hospital so that outsiders would not know about them.

    M9:

    I took the initiative to ask the doctor in charge to be involved in the selection of the donor sperm, hoping to get good sperm from a well-educated, healthy and good-looking donor.

    M12:

    I would like to know if the hospital can provide support to check if the child is related to the person in order to avoid consanguineous marriage when the child is old enough to talk about marriage.

    Psychological Support for Daughters

    Mothers help their daughters to cope better with the challenges of the treatment process, reduce anxiety and increase confidence through emotional care and positive communication styles during their daughters’ treatment.

    M10:

    I will talk to her regularly, listen to her feelings and concerns and let her know that I will always be there to support her.

    M5:

    I found some success stories online and told her that many people have gone through this process and ended up happy. That way she won’t feel alone and she’ll know she’s not the only one.

    M11:

    Whenever she gets frustrated, I tell her how brave and strong she is and that I am sure she will succeed.

    M6:

    I would do some relaxation exercises with her, such as deep breathing or meditation, to help her reduce stress and cope better with the challenges of the treatment process.

    Discussion

    Attending to the Mother’s Psychological State and Providing Personalized Emotional Support Strategies

    At present, research on the mental health of infertile patients focuses primarily on the psychological status of the couple, while relatively little research has been done on the psychological status and emotional experience of the mother, who is an important source of emotional support for the female patient.14–17 The present study set out to explore the emotional responses of the mother of the female partner when she became aware that her son-in-law was azoospermia and required the use of a donor sperm to fulfil her daughter’s desire to have a child with him. The emotional reactions of the mother fell into three distinct categories: shock and anger, rationality and tolerance, as well as secret joy and relief. The variation in these emotional responses highlights significant disparities in individual psychological attributes, understanding of infertility, and attitudes towards sperm donation.18,19 Therefore, it is important to understand the emotional experience and psychological state of mothers of female patients in order to provide more comprehensive psychological support and interventions, and to help infertile donor families make more reasonable fertility choices.20 It is incumbent upon the medical staff to formulate suitable emotional support strategies in line with the mother’s level of education and her ability to comprehend, to actively listen to her emotional needs and concerns by means of face-to-face communication, and to provide psychological counselling and mental health lectures with the participation of family members so that she can feel concerned and respected.21 In this process, medical personnel can facilitate mothers’ understanding of the ethics of sperm donor insemination, the treatment process, precautions, relevant laws and regulations, and so forth. This can be achieved through the utilization of various educational tools, including information brochures, health education videos, and online platforms.22,23

    Deepening Understanding of Women’s Family Support Needs and Exploring the Role of Mothers in Fertility Decision-Making

    The decision-making process for donor sperm assisted reproduction treatment, as a specific socio-culturally constructed treatment, involves not only the couple, but also the support of both families, with the woman’s mother, in particular, playing a crucial role.24 The findings of this study indicate that the impact of mothers on their daughters’ decision-making process regarding donor sperm is characterized by a combination of positive and potentially adverse influences. These influences are thought to be shaped by traditional concepts of fertility, cultural backgrounds, and marital experiences.25 On the one hand, mothers are able to provide their daughters with the necessary emotional and financial support,26 especially when they are faced with the uncertainty and psychological stress associated with donor sperm, and their support and protection can significantly reduce their daughters’ anxiety and increase their confidence in the treatment process.7,8 On the other hand, mothers often expressed concerns about the complicated medical procedures their daughters underwent, such as salpingography, artificial insemination, ovarian stimulation, oocyte retrieval, and embryo transfer, and worried about their daughters’ future.27,28 For example, a mother may worry about the unhappiness her daughter faces after marriage and the possible problems of child support and belonging caused by the breakup of the couple’s relationship.29,30 This concern will increase dissatisfaction with the son-in-law, which will complicate the decision of the daughter and son-in-law to use donor sperm for pregnancy, which will cause tension in the daughter’s family relationship.31 To effectively manage the mother’s involvement in their daughters’ decision-making, medical professionals must encourage couples to carefully consider the need for emotional support against the desire for privacy when deciding whether to inform the mother of female patients about donor sperm treatment. In order to understand the mother’s attitudes and their possible impact, family structures and relationships must be assessed, thus enabling the design of individualized family support strategies for the couple.32 Furthermore, it is imperative that health professionals maintain an impartial stance throughout the process, demonstrating respect for the emotional requirements and the prerogative of the couple to reach a decision. This encompasses the decision of whether to inform the mother or to maintain confidentiality. Additionally, it is essential to provide a secure environment that fosters autonomy, enabling the couple to select the decision-making method that most aligns with their preferences.33

    Strengthening Healthcare Workers’ Awareness of Privacy Protection to Alleviate Mothers’ Concerns About Privacy Breaches

    Research undertaken in both domestic and international contexts has demonstrated that a significant proportion of individuals experiencing infertility encounter issues related to discrimination and shame within their respective social and familial environments.34–36 This phenomenon has been found to exert a detrimental influence on the mental well-being of the affected individuals, with the potential to engender interpersonal tensions within marital relationships, thereby compromising the quality of the relationship itself.37 A particular concern pertains to women who have recourse to sperm donor assistance in conception, a demographic that faces a heightened degree of psychological, social, ethical, and moral pressure when compared to other infertility patients. This heightened pressure can be attributed to the distinctive nature of the sperm source employed in their treatment.38 Research has indicated that such women encounter significant challenges in adapting to married life and are predisposed to an elevated risk of divorce.36 This study found that women participating in sperm donor treatment, their partners, and their mothers generally placed a high value on privacy protection and expressed great concern about the risk of privacy disclosure. It is therefore important for medical institutions to strengthen medical staff’s awareness of the protection of patients’ privacy, not only out of respect for patients’ privacy, but also in order to maintain the level of trust in the doctor-patient relationship. It is imperative to recognize that any breach in confidentiality, whether intentional or inadvertent, can have severe legal ramifications for medical staff, potentially eroding the trust patients and their families place in the healthcare organisation.39 Consequently, medical institutions are obliged to adhere strictly to the Code of Practice for Assisted Human Reproduction Technology and the Ethical Principles for Assisted Human Reproduction Technology and Human Sperm Banks, in addition to other pertinent regulations.40 They must establish and implement an effective privacy protection system, with the aim of minimizing unnecessary doctor-patient disputes.

    In the context of the ‘Internet Plus’ initiative and the rapid advancements in artificial intelligence (AI), there is a growing imperative for medical institutions to enhance the security protocols of their electronic medical record systems. This enhancement aims to ensure the comprehensive protection of patient information across all facets of medical consultations, guidance, treatment registries, and health education. In addition to this, medical institutions are strongly advised to adhere to the stipulated requirements of the Recommendation on the Ethical Issues of Artificial Intelligence when employing AI-assisted reproduction technology.41,42 This entails the encryption of sperm supply data and the implementation of stringent access control measures to bolster data security. Regular targeted training and educational initiatives should be provided to medical staff, emphasizing the significance of privacy protection and the legal obligations. These measures are crucial to enhance the awareness of medical workers regarding privacy protection and to ensure compliance with the relevant laws and regulations.

    Multi-channel health education programs, the Internet and new media platforms represent a multifaceted approach that healthcare providers can utilize to address the needs of patients in the field of reproductive medicine. Beyond the provision of essential knowledge, these initiatives also seek to enhance social support and foster positive doctor-patient relations.43 The implementation of these strategies has been shown to alleviate fear, tension and shame experienced by patients and their families during the treatment process, thereby promoting a more conducive environment for treatment. The enhancement of public health literacy and the dissolution of the constraints imposed by traditional attitudes are pivotal in fostering a more profound understanding and inclusivity towards donor sperm assisted conception within society. This progressive shift is poised to engender a more compassionate and supportive environment, thereby promoting the psychological well-being of patients and enhancing their confidence and satisfaction throughout the treatment process.23

    Limitations

    The present study is subject to several limitations. Firstly, the majority of the treatments received by the respondents’ daughters were AID, with only a few cases of D-IVF. There were differences in the treatments that the women needed to undergo between the two treatments; the women who received D-IVF underwent an additional egg retrieval surgery, which resulted in a more protracted and intricate treatment process and may have had an impact on the psychological experience and decision-making, which could be investigated in future studies. Secondly, patients were from only one reproductive center, which may have led to selective bias. In the future, multi-center and larger sample sizes will be conducted, and random sampling methods will be used to conduct a multi-regional and multi-center study to increase the reliability of the results. Finally, the present study exclusively examined the emotional experience and decision-making process of the female patients’ mothers. Subsequent research could broaden the perspective to encompass the patients themselves and other relatives, thereby facilitating a more comprehensive understanding of the potential influencing factors in the decision-making process of sperm-assisted conception. This would provide a foundation for enhancing the experience of sperm-assisted conception and interventions, and consequently increasing the fertility intentions and quality of life of the patients.

    Conclusions

    This study utilized semi-structured interviews with 12 mothers whose daughter had undergone ART treatment, with the objective of comprehending their genuine sentiments during the period of discerning and deliberating on their daughter’s necessity for ART treatment. The study posits that medical professionals ought to be cognizant of the potential mental health challenges faced by those mothers who assume an invisible role in their daughters’ reproductive decision-making and treatment processes. It is recommended that these mothers be offered bespoke emotional support strategies. The study’s findings contribute to the exploration of the role of mothers in reproductive decision-making according to the needs of women, with a view to improving awareness of privacy protection, reducing the mother’s concern about privacy disclosure, and enhancing the confidence and satisfaction of the entire family during the treatment process.

    Patient Consent

    After explaining the purpose and content of the study to the patients, the informed consent of the patients was obtained for this study, and the paper version of the informed consent was signed. All patient information will be anonymized in the study to eliminate the risk of privacy disclosure. All patients have given consent for publication of anonymous responses and direct quotes.

    Acknowledgments

    We are grateful for everyone involved in this study.

    Author Contributions

    All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

    Funding

    This research is funded by the Zhejiang Province Traditional Chinese Medicine Science and Technology Plan Project (Grant No. 2024ZF100, 2024KY112).

    Disclosure

    The authors declare that there is no potential conflict of interest in this work.

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  • AI reveals hidden bias behind higher amputation rates in minority and rural patients

    AI reveals hidden bias behind higher amputation rates in minority and rural patients

    Why do rural adults and racial and ethnic minorities with vascular disease get major leg amputations more often? A new study out today in Epidemiology uses AI to solve the mystery, finding an unaccounted-for factor that researchers think points to implicit bias in the clinical decision-making process.

    The AI model allowed us to distinguish among the many reasons behind these much higher rates of amputation among certain groups of people with vascular disease. We found that, after accounting for everything else, people’s unconscious biases are likely behind why some groups receive amputation instead of alternative treatment that preserves their limb.” 


    We hope our results will be a catalyst to create evidence-based guidelines that help vascular surgeons and other providers who make this life-changing decision do so objectively.” 


    Paula Strassle, lead author and assistant professor of epidemiology at UMD’s School of Public Health

    More than 12 million adults in the US live with a vascular disease called Peripheral Artery Disease (PAD), a chronic circulation condition that restricts blood flow to the limbs. It results in leg pain, numbness and in severe cases, limb loss. About 10% of people with PAD develop Chronic Limb-Threatening Ischemia (CLTI) at which point either they receive a procedure to restore blood flow to their lower leg or their limb must be amputated. Revascularization is a surgical procedure that can save the limb, but it also requires intensive follow-up and is a relatively expensive surgical procedure. Vascular surgeons are also in short supply. 

    After accounting for known differences in clinical presentation, the study found higher rates of amputation among Black, Hispanic, Native American, and white people in rural areas as well as among Black and Native American people in urban areas. After further accounting for differences in hospital and neighborhood resources, higher amputation rates persisted among Black, Hispanic, and Native American people in rural areas, and Black and Native American people in urban areas.

    “We found a substantial unexplained portion that would suggest an implicit bias in clinical decision-making occurring at the physician and hospital level,” Strassle said. 

    The study examined hospitalizations between 2017 and 2019 of people under 40 with PAD or CLTI, across five states (Florida, Georgia, Maryland, Mississippi and New York) using State Inpatient Databases from the Healthcare Cost and Utilization Project. 

    Researchers programmed an AI model to consider a huge number of variables (70+) that contribute to known reasons for differences in leg amputations of people with PAD. Variables included clinical factors such as age and other health conditions, healthcare system capacity to perform revascularization and limb amputations, legal and regulatory climate, and the physical environment such as a person’s distance to the nearest emergency room and ZIP code median income. 

    “This AI model will allow us to easily assess intersectionality across race, sex, income and rurality, and offers us the ability to indirectly study hard-to-measure causes of disparities, like implicit bias and stereotyping,” said Strassle. 

    Limb-threatening conditions are often the result of decades of difficult-to-control diseases like diabetes, high cholesterol and nicotine dependence. For surgeons, who know these conditions lead to worse surgical outcomes, this can make the decision to pursue a complex limb-saving surgery even trickier. 

    “As vascular surgeons we have surgical guidelines, but we don’t have detailed guidelines to help us make the decision between amputating someone’s leg and limb-saving surgery in patients who are not medically ready. Given the number and complexity of variables involved, we need more information describing the optimal treatment for each person in different conditions. We need to know we can perform a successful vascular operation, and also not increase the risk of dying,” said Katharine McGinigle, a vascular surgeon, associate professor of surgery at the University of North Carolina and senior author of the paper. 

    “There are so many medical, surgical, and social factors that contribute to disease progression, limb-loss and even death. Surgeons and others making treatment recommendations deserve evidence-based guidance that will help us avoid unconscious biases and make the right decision at the right time for each person based on their unique clinical and social needs. AI methods, similar to the one used in this research, can help us achieve that goal,” said McGinigle.

    Strassle and McGinigle hope that their findings will inform comprehensive guidelines and health policies that help clinicians avoid unconscious bias and other unjustified differences in the quality of care provided, to safely save limbs of people living with advanced vascular disease. 

    Source:

    Journal reference:

    Strassle, P. D., et al. (2025). Disaggregating health differences and disparities with machine learning and observed-to-expected ratios: Application to major lower limb amputation. Epidemiology. doi.org/10.1097/ede.0000000000001892.

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  • Earth is spinning faster than usual today. Here's why – MSN

    1. Earth is spinning faster than usual today. Here’s why  MSN
    2. Time keeps on slipping – literally. Why today might have been the shortest day you’ll ever experience  MSN
    3. The Earth’s Clock Is Wobbling – And 3 Days This Year Will Be Just A Bit Too Short  MSN
    4. July 9 2025 labelled the ‘shortest day’ in Earth’s history  MSN

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  • King Charles faces scathing criticism over new move

    King Charles faces scathing criticism over new move

    King Charles sparks backlash with controversial banquet move

    King Charles has been criticised for inviting French chef Raymond Blanc to help prepare the state banquet during President Emmanuel Macron’s visit.

    According to former royal chef Darren McGrady, monarch’s decision was a “huge slap in the face” to the palace’s own chefs.

    Blanc, who has a long-standing relationship with the King, was asked to assist with the first course and dessert.

    Speaking with Mail Online, McGrady, who was a personal chef to the late Queen Elizabeth, Princess Diana, her kids, Prince William and Prince Harry, criticised Charles’ new move.

    “I get that Raymond Blanc is one of the best chefs in the world, and I get that he is a King’s Foundation ambassador, and I get that ‘the collaboration is in the spirit of Entente Cordiale (a cordial agreement)’ but it’s a huge slap in the face to the palace royal chefs,” he said.

    “For sure, Macron will not be bringing in British chefs for a King Charles state visit to France,” he added.

    Per The Mirror, Blanc was asked to assist the palace’s chefs to “create the first course and dessert.”

    When asked to assist with the main course, the chef left that responsibility to Mark Flanagan, the head chef of the Royal Household.


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