PErioperative respiratory care aNd outcomes for patients underGoing hIgh risk abdomiNal surgery (PENGUIN): a randomised international internal pilot trial

Background

Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO2) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed.

Methods

Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80-100% perioperative FiO2 to prevent surgical site infection (SSI) versus 21-35% FiO2. This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days.

Results

We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO2 increases in the 21-35% FiO2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events.

Conclusion

This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs.

Trial registration

ClinicalTrials.gov NCT04256798.

Critical evaluation of sentinel lymph node biopsy in pT1b and pT2a melanoma patients: A nationwide population-based study

INTRODUCTION

Sentinel lymph node biopsy (SLNB) aims to stage patients. According to the 8th edition of the American Joint Committee on Cancer(AJCC) staging manual, patients with pT1b or pT2a melanoma can be eligible for adjuvant immunotherapy, however, only if they have a sentinel node (SN) tumour burden > 1 mm. This study aims to determine the percentage of patients with pT1b or pT2a that will become eligible for adjuvant immunotherapy following SLNB.

METHODS

A nationwide, population-based study was conducted using data from the Dutch Pathology Databank. Patients diagnosed with pT1b and pT2a melanoma between 2002 and 2023 were included. The primary endpoint was the number of SNs with a tumour burden > 1 mm.

RESULTS

We identified 36,606 patients of who 16,042 underwent SLNB. SN positivity was 5 % for patients with pT1b melanoma, and 11 % for pT2a melanoma. A tumour burden > 1 mm was found in 1.5 % and 4.1 %, translating to a number needed to treat (NNT) of 69 for pT1b and 25 for pT2a.

CONCLUSION

This nationwide study demonstrated a low incidence of positive SNs and minimal likelihood of significant clinical outcomes following SLNB. Given the high NNT to be eligible for adjuvant immunotherapy, SLNB may no longer be justified for pT1b melanoma. For patients with pT2a melanoma, SLNB should be considered carefully, balancing limited clinical benefits against potential risks.

CRKL silencing inhibits melanoma growth and enhances its chemotherapy sensitivity through the PI3K/AKT and NLRP3/GSDMD pathways

Great advances have been made in malignant melanoma treatments, whereas drug resistance still limits many drug applications. CRKL has been reported to be overexpressed in various tumors and showed poor prognosis. However, its specific function and mechanism in melanoma remain unclear. In the present study, we investigated the expression of CRKL and its clinical association by bioinformatics and clinical analysis, and then performed a series of in vitro and in vivo experiments to demonstrate its function and mechanism. Results showed that CRKL increased during melanoma progression and was strongly associated with poor prognosis. CRKL silencing effectively inhibited melanoma cell growth and invasion via ERK/MMP9 and PI3K/AKT signaling pathways both in vitro and in vivo. Moreover, CRKL silencing induced pyroptosis in melanoma cells by upregulating the levels of pyroptosis-associated proteins, such as NLRP3, cleaved Caspase-1, and GSDMD-N. Importantly, our study demonstrated that interfering with CRKL expression enhanced the chemotherapy sensitivity of melanoma cells to cisplatin by regulating PI3K/AKT and NLRP3/GSDMD signaling pathways. In conclusion, our study uncovers a novel molecular mechanism by which CRKL functions in melanoma and highlights potential therapeutic strategies for improving chemotherapy sensitivity in melanoma patients.

Current usage and diagnostic performance of cross-sectional imaging in patients with suspected acute appendicitis: a national survey in China

PURPOSE

The role of cross-sectional imaging in the management of acute appendicitis (AA) is contentious. This study aimed to investigate the current usage and diagnostic performance of ultrasound (US) and computed tomography (CT).

METHODS

A national survey was conducted by a core group from The National Ultrasound Quality and Control Center of China among radiologists practicing in medical institutions equipped with emergency departments and regularly performing appendectomies. Radiologists participated by completing the survey online from August 2022 to August 2023 after reviewing medical records of at least 40 patients with suspected AA. Sensitivity, specificity, positive predictive value, and negative predictive value and likelihood ratios were calculated for US and CT, respectively. Diagnostic performance of US between hospital subgroups were also compared.

RESULTS

A total of 141 questionnaires were submitted and 118 were eligible, each representing a distinct hospital. A total of 1844 children and 4165 adults were included. There were 76.4% patients underwent US studies, while 23.9% underwent CT studies. Higher percentage of children underwent US studies than adults (82.2% vs. 73.9%, P = 0.000). In children, the sensitivity and specificity of US were 89% and 90%, and of CT were 90% and 48%. In adults, the sensitivity and specificity of US were 92% and 84%, and of CT were 94% and 79%. The Likelihood ratios of US were higher in specialized hospitals (children's or children's and women's hospitals) than general hospitals (34.1 vs. 6.43).

CONCLUSION

US is more commonly used than CT for diagnosing AA in both adults and children. The diagnostic performance of US is comparable to CT. These findings underscore the recognition of US in clinical practice as a low-cost, non-radiative tool.

The Third Pillar of Precision Medicine - Precision Delivery

Precision Medicine is thought of as having two main pillars: Precision Diagnosis and Precision Therapy. However, for Precision Medicine to reach its full potential, a third pillar is needed that we propose to call Precision Delivery. In the laboratory, many therapies show great efficacy when tested directly with target cells. However, upon clinical translation, they are often given via intravenous or oral administration, resulting in their systemic distribution. To ensure therapies reach target sites at the correct therapeutic levels, they are often given at higher concentrations. However, this can be associated with off-target effects, side-effects, and unwanted interactions. Delivery strategies can help mitigate this by "spatially re-coupling" therapies in vivo with target cells. This review explains the concept of Precision Delivery, which can be thought of as three interconnected, but independent, modules: targeted delivery, microenvironment modulation, and cellular interactions. While locoregional approaches directly deliver therapies into target tissues through endovascular, endoluminal, percutaneous, and implantation techniques, microenvironment modulation technologies facilitate the movement of therapies across biological barriers and through tissue matrices, so optimized therapies can reach and interact with target cells. We highlight new innovations driving advances in Precision Delivery, while also discussing the considerations and challenges that Precision Delivery faces as it becomes increasingly integrated into treatment workflows.

Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis

INTRODUCTION

Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA.

METHODS

This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events.

RESULTS

The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%-96.7% vs 90.5%; 95% CI, 87.6%-92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07-0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%-8.2% vs 9.5%; 95% CI, 7.1%-12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3-4] vs 4 [IQR, 4-6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210-318] vs 70 [IQR, 21-103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064).

DISCUSSION

V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.

Mega-authorship implications: How many scientists can fit into one cell?

The past 20 years has seen a significant increase in articles with 500 or more authors. This increase has presented problems in terms of determining true authorship versus other types of contribution, issues with database metadata and data output, and publication length. Using items with 500+ authors deemed as mega-author titles, a total of 5,533 mega-author items were identified using InCites. Metadata about the items was then gathered from Web of Science and Scopus. Close examination of these items found that the vast majority of these covered physics topics, with medicine a far distant second place and only minor representation from other science fields. This mega-authorship saw significant events that appear to correspond to similar events in the Large Hadron Collider's timeline, indicating that the projects for the collider are driving this heavy output. Some solutions are offered for the problems resulting from this phenomenon, partially driven by recommendations from the International Committee of Medical Journal Editors.

MORTALITY OF SEPTIC SHOCK SECONDARY TO PEDIATRIC PRIMARY PERITONITIS PREDICTED BY RESPIRATORY QUOTIENT COMBINED WITH LACTATE: A SURVEY FROM TWO CHILDREN'S HOSPITALS IN NORTHWEST CHINA

ABSTRACT

Background: Pediatric sepsis is a life-threatening condition, with extremely high incidence and mortality among critically ill children worldwide. Patients with septic shock are susceptible to intestinal complications due to altered blood flow distribution, and these complications often correlate directly with a poor prognosis. Early detection of low perfusion and appropriate resuscitation are critical components in the management of patients experiencing shock. Nevertheless, significant debate persists regarding the comparative value of various resuscitation targets. While central venous oxygen saturation (ScvO2) monitoring is frequently advocated, it remains a subject of scrutiny. All pathophysiological mechanisms are intricately linked to cellular hypoxia and energy metabolism, which is why metabolic-related biomarkers, particularly lactate and lactate clearance rate, are highly regarded by critical care experts. Nonetheless, limited research has been conducted on the association between markers of circulatory shock and metabolic disorders in critically ill patients particularly in the field of pediatrics. Physiological indicators, particularly those associated with cell energy metabolism, have shown potentials in predicting sepsis and septic shock. Methods: This was a retrospective study. A total of 63 patients, comprising 30 males and 33 females, who developed septic shock secondary to pediatric primary peritonitis, were admitted to the Intensive Care Department of the Children's Hospital Affiliated to Xi'an Jiaotong University and the Pediatric Intensive Care Unit of Gansu Provincial Maternity and Child-Care Hospital between December 2016 and December 2021. Based on the primary outcome of 28-day all-cause mortality, patients were assigned into the survival group and nonsurvival group. Demographic and clinical data were compared. Risk factors for the prognosis of septic shock secondary to pediatric primary peritonitis were identified by logistic regression, and their potentials in predicting the 28-day survival were assessed by the receiver operating characteristic and Kaplan-Meier survival curves. Results: Among the 63 eligible patients with septic shock secondary to pediatric primary peritonitis, 47 survived. In comparison to the survival group, the nonsurvival group showed significantly higher proportions of mechanical ventilation, surgical intervention, and use of vasoactive drugs, procalcitonin, activated partial thromboplastin time, respiratory quotient (RQ), lactate (Lac), the Pediatric Sequential Organ Failure Assessment score, and the Pediatric Risk of Mortality III score, but lower platelet count, fibrinogen, and mean arterial pressure (all P's < 0.05). RQ (odds ratio [OR], 2.37; 95% confidence interval [CI], 1.41, 3.22; P < 0.05) and Lac (OR, 2.01; 95% CI, 1.15, 3.21; P < 0.05) were independent prognostic factors for septic shock secondary to pediatric primary peritonitis. Their combination (RQ < 1.6 + Lac < 4 mmol/L) achieved a better accuracy in predicting the 28-day cumulative survival. Conclusion: RQ combined with Lac offers an excellent performance in predicting mortality of septic shock secondary to pediatric primary peritonitis.

Automated assessment of skin histological tissue structures by artificial intelligence in cutaneous melanoma

BACKGROUND

Prognostic histopathological features such as mitosis in melanoma are excluded from the staging systems due to inter-observer variability and time constraints. While digital pathology offers artificial intelligence-driven solutions, existing melanoma algorithms often underperform or narrowly focus on specific features, limiting their clinical utility.

OBJECTIVE

Develop and validate an automated artificial intelligence-driven segmentation framework to identify multiple histological tissue structures within cutaneous melanoma images.

METHODS

Employing 157 melanoma whole slide images, U-Net and DeepLab3+ classifiers were independently trained Oncotopix ® platform using manual annotations, to detect specific histological features, termed application. All the applications are progressively executable. The performance of each application was measured when both operating independently and with sequential detection when applied to ten independent validation set images using accuracy and F1-score as metrics. The model was further validated by applying it to 442 whole-slide melanoma images, with dermatopathologists reviewing the segmentation outputs.

RESULTS

Seven applications were developed for progressive automated detection: Whole tissue (1) and tumour microenvironment (TME) (2), Hair follicles & sebaceous gland (3) within TME, ulceration (5), and melanoma cell area (6) based on DeepLab3+. Epidermis (4) and mitosis within the tumour area (7) based on U-Net. The applications demonstrated over 92 % accuracy and F1-score surpassing 80 %, except for the ulceration application (F1-score = 75 %). The pathologist examination indicated that 92 % of the 442 images had correct segmentations.

DISCUSSION AND CONCLUSION

The developed applications demonstrated high performance, enhancing the analysis of time-consuming histological features. The model facilitates the identification of histopathological features in large datasets allowing potential refinement of melanoma staging.

Quality improvement program for the severely injured

Over recent decades, advancements in trauma care have significantly reduced mortality rates among severely injured patients. These improvements are largely attributable to the establishment of trauma care systems, including prehospital management protocols and the creation of trauma centres with immediate surgical team availability. However, patient outcomes continue to vary, reflecting differences in the quality of trauma care influenced by organisational models and local practices. To address this, governments and scientific organisations have underscored the importance of evaluating care quality at local, national, and international levels. This chapter explores strategies for assessing quality of trauma care, establishing reliable quality indicators (QIs), and standardising auditing processes to guide improvements in patient outcomes and system performance.

Open abdomen versus primary closure in the management of severe abdominal sepsis: What is the right way? Results of the last 5 years of a reference center

PURPOSE

WSES guidelines allow open abdomen (OA) for critically ill patients due to secondary peritonitis in the case of inadequate source control, but this option results quite vague and with a low grade of evidence (Grade 2 C). Moreover, the emerging increasing in literature of complications, makes the use of OA in secondary peritonitis more debated. The aim of our study is to analyze the postoperative outcomes of patients undergoing OA versus primary closure (PC) in secondary peritonitis.

METHODS

We collected data from Tertiary Trauma Center from 2019 to 2024. The study included patients who underwent urgent laparotomy for severe secondary peritonitis, divided into two groups based on the strategy chosen in the index laparotomy: PC or OA. We retrospectively analyzed the data, considering as primary outcome post-operative mortality, while as secondary outcomes short terms complications and LOS.

RESULTS

283 patients fit the research for the diagnosis of peritonitis but only 176 were included as with a WSES-SSS > = 7. 128 patients (72,7%) were in the PC group, while 48 (27,3%) were managed with an OA strategy. There were no statistical differences in terms of mortality (p = 0.371), between the two groups. Complications were higher in the OA group (p = 0.001). From the logistic regression only MPI resulted an independent factor of mortality (p = 0.016; OR 1.080).

CONCLUSION

The study shows that OA in severe secondary peritonitis does not improve mortality and is associated with higher short-term complications and incisional hernias. However, RCT are necessary to better investigate the role of OA in the management of abdominal sepsis.

Locoregional Non-Surgical Treatments for Unresectable or Oligometastatic Sarcomas: A Literature Review

OPINION STATEMENT

Sarcomas are rare neoplasms, whose complex management is a consequence of their heterogeneity. Due to their variegate histology and characteristics, prospective trials are challenging to design. Thus, diagnostic and therapeutic guidelines are often based on limited evidence available, and only few and dated systemic treatment regimens are included in our current practice. For all these reasons, we believe that implementing therapeutic options, including local approach, is mandatory to guarantee the best management possible to patients. We explored evidence about locoregional treatments, assuming they could represent a fundamental part of an integrated oncological approach. The goal is to maximize local control of oligometastatic or oligoprogressive diseases, saving systemic treatment options for later stages, as well as to avoid demolitive surgery in patients affected by locally advanced sarcomas. Although several retrospective and prospective series have been conducted, evidence available is still poor in our opinion. Research should focus on evaluating predictive factors and individualized follow up strategies to identify ideal patients' features and more sensitive histological subtypes.

Risk factors for in-hospital mortality in surgical patients with abdominal sepsis in China: a nested case-control study

OBJECTIVES

To delineate the clinical characteristics and investigate the determinants that may affect the prognosis of surgical patients with abdominal sepsis.

DESIGN

A case-control study was nested in a cohort of surgical patients with abdominal sepsis between 2008 and 2022. We extracted patient' medical records to execute descriptive statistical analyses. Multiple logistic regression models and subgroup analysis were employed to elucidate the risk factors of in-hospital mortality.

SETTING

Two tertiary hospitals in China.

PARTICIPANTS

476 surgical patients diagnosed with abdominal sepsis between 2008 and 2022 were analysed.

INTERVENTIONS

None.

OUTCOME MEASURES

Descriptive statistics were used to examine pertinent patient information, including demographic details, laboratory findings, surgical interventions and anaesthetic records. Multivariate logistic regression was used to identify independent risk factors for in-hospital mortality. Subgroup analyses were conducted to explore the impact of specific clinical characteristics on outcomes.

RESULTS

476 patients diagnosed with abdominal sepsis were analysed, exhibiting an in-hospital mortality rate of 7.56%. Advanced age (OR 6.77, 95% CI 2.46 to 18.66, p<0.001), the presence of diabetes (OR 2.61, 95% CI 1.04 to 6.56, p=0.041) and higher preoperative Sequential Organ Failure Assessment (SOFA) score (OR 3.48, 95% CI 1.16 to 10.43, p=0.026) were identified as significant predictors of increased in-hospital mortality risk through a multinomial logistic regression model. Conversely, individuals afflicted with biliary diseases (OR 0.15, 95% CI 0.04 to 0.64, p=0.010) demonstrated a reduced risk of in-hospital mortality. Subgroup analysis revealed that low serum albumin levels emerged as a risk factor for in-hospital mortality in the patients with gastrointestinal diseases (OR 20.23, 95% CI 2.21 to 184.84, p=0.008) or advanced age (OR 10.52, 95% CI 2.29 to 48.31, p=0.002) through multinomial logistic regression analysis.

CONCLUSION

In this retrospective analysis, we delineated the clinical characteristics of surgical patients with abdominal sepsis and pinpointed risk factors associated with in-hospital mortality. These findings underscore the necessity for more tailored perioperative management strategies for patients with sepsis characterised by advanced age, diabetes, higher preoperative SOFA score and reduced preoperative albumin levels. Clinicians should prioritise early recognition and aggressive management of these high-risk individuals, including timely surgical intervention, optimisation of nutritional status and vigilant monitoring of organ function. These insights underscore the critical role of individualised care in enhancing the prognosis of surgical patients with abdominal sepsis.

TRIAL REGISTRATION NUMBER

ChiCTR2400081823.

Clinical and financial impact of a 'difficult' laparoscopic cholecystectomy

BACKGROUND

Difficult intra-operative findings during laparoscopic cholecystectomy (LC) may lead to poor clinical outcomes. This study aimed to compare pre-operative, intra-operative, and post-operative variables of patients with 'straightforward' versus 'difficult' intra-operative findings and to assess the relationship between intra-operative findings and post-operative outcomes.

METHODS

A retrospective cohort study of prospectively collected data from patients undergoing LC from August 1998 to December 2020 was conducted. Intra-operative findings were graded using the North Shore system, with Grade 1 or 2 classified as 'straightforward' LC and Grade 3 or 4 as 'difficult' LC. Logistic regression analyzed the relationship between poor post-operative outcomes and intra-operative findings.

RESULTS

Among 2633 patients, 2050 (78%) had 'straightforward' and 583 (22%) had 'difficult' intra-operative findings. Patients with 'difficult' findings were often younger, male, jaundiced, had higher Charlson Comorbidity Indexes (CCI), and were more likely to undergo urgent or semi-urgent operations in the public hospital. They experienced longer operation times, higher cholangiogram failure rates, more common bile duct explorations, longer hospital stays, higher conversion rates to open procedures, a greater risk of post-operative bile leaks, and higher rates of hospital readmission post-discharge. Higher CCI, pancreatitis, and intra-operative challenges such as CBD exploration and 'difficult' intra-operative findings were predictive of poor post-operative outcomes. The financial impact of 'difficult' intra-operative findings is significant.

CONCLUSION

There is an association between 'difficult' intra-operative findings and adverse clinical outcomes, confirming the negative financial impact of a less-than Textbook Outcome. This highlights the need to anticipate and make appropriate resources available for potentially challenging LCs.

Trends in Clinical Outcomes After Major Emergency Abdominal Surgery in Denmark, Data From 2002-2022

Importance

Major emergency abdominal surgery is associated with high morbidity and mortality. Understanding trends in outcomes over time can reveal critical practice-changing improvements, identify gaps in postoperative care, and establish a large-scale benchmark for future research.

Objective

To investigate trends in morbidity and mortality after major emergency abdominal surgery in Denmark.

Design, Setting, and Participants

This was a nationwide, population-based cohort study. Analyses were performed based on data from Danish nationwide administrative registries. Within the public health care system in Denmark, all adult patients undergoing major emergency abdominal surgery from 2002 to 2022 were included. Major emergency abdominal surgeries included laparotomy or laparoscopy due to intra-abdominal pathologies, including intestinal perforation, ischemia, bowel obstruction, abscess, or bleeding.

Exposure

Major emergency abdominal surgery.

Main Outcomes and Measures

The primary outcome was the trend in 30- and 90-day mortality after major emergency abdominal surgery over time.

Results

A total of 61 476 patients (mean [SD] age, 66.2 [16.3] years; 34 827 female [56.7%]) were included. The annual number of surgeries remained constant, with a mean (SD) of 3044 (165) surgeries per year. The 30- and 90-day mortality was reduced from 25% and 33%, respectively, to 13% and 18%, respectively (P < .001). Median (IQR) hospital length of stay was decreased from 10 (5-17) days to 6 (4-13) days (P < .001). The rate of 30-day postoperative complications (classified Clavien-Dindo ≥3a) was reduced from 49% to 44% (P <.001) and the 90-day rate was reduced from 53% to 48% (P <.001), however, with a tendency toward more patients undergoing earlier intervention. The 30- and 90-day readmission rate increased drastically from 9% and 13%, respectively, to 25% and 33%, respectively (P < .001).

Conclusions and Relevance

Results of this cohort study suggest notable reductions in mortality and hospital length of stay after major emergency abdominal surgery. A marked increased readmission rate and a persistently high rate of postoperative complications were found. These shifts underscore the need for enhanced postoperative monitoring and postdischarge follow-up.

Treatments and cancer: implications for radiologists

This review highlights the critical role of radiologists in personalized cancer treatment, focusing on the evaluation of treatment outcomes using imaging tools like Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Ultrasound. Radiologists assess the effectiveness and complications of therapies such as chemotherapy, immunotherapy, and ablative treatments. Understanding treatment mechanisms and consistent imaging protocols are essential for accurate evaluation, especially in managing complex cases like liver cancer. Collaboration between radiologists and oncologists is key to optimizing patient outcomes through precise imaging assessments.

Epidemiology of Pediatric Transports and First Aid in a German Municipal Emergency Medical Services (EMS) System: A Cohort Study

Background: Pediatric emergencies remain a significant challenge for emergency services. The study aimed to retrospectively analyze invasive measures and medication administered during prehospital care. The analysis focused on invasive procedures (e.g., tracheal intubation and vascular access) performed on pediatric patients (aged 1 month to 12 years) admitted via the Central Emergency Department (ED) or directly to the University Pediatric Intensive Care Unit (PICU) of the University Hospital of Cologne. These findings provide insights into quality assurance and improvement of prehospital care and invasive emergency techniques in pediatrics. Methods: Emergency protocols were evaluated, including parameters such as the Glasgow Coma Scale (GCS) and National Advisory Committee for Aeronautics (NACA) score. Patients were categorized based on diagnosis, medication administration, and invasive emergency techniques. Results: A total of 373 patients were admitted to the ED, and 237 patients were admitted to the PICU between 01/2015 and 05/2020. Sedation was at similar in both groups, while catecholamines were more frequently used in the PICU group. Invasive procedures, such as tracheal intubation, were rare (PICU: 9.5%; ED: 5.8%; p=0.093). Peripheral venous access was performed in 33.7% of PICU cases and 51.2% of ED cases, whereas central venous access was almost never performed. 19 children admitted to the PICU died compared to one in the ED (p < 0.001). Conclusion: Invasive procedures are rarely performed during prehospital care for pediatric patients. Trauma cases predominated in the ED group (99.2%), whereas the PICU group exhibited greater diagnostic variability, including trauma and internal emergencies. This study identified significant gaps in medical documentation. Training for paramedics and emergency health workers should prioritize airway management, including supraglottic airway (SGA) devices, thoracic drainage, and vascular access techniques such as peripheral intravenous (PIV) and intraosseous (IO) access. Additionally, efforts to improve medical documentation should be emphasized to enhance pediatric emergency care.

Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

AIM

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

METHODS

This study was a population-based retrospective case-control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

RESULTS

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17-1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22-1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68-2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28-1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09-2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06-3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07-1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79-2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14-1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08-1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94-3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20-1.89), paralysis (OR = 3.24; 95% CI = 1.95-5.38), and weight loss (OR = 2.34;95% CI = 1.26-4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46-15.23), blood transfusion (OR = 1.51; 95% CI = 1.31-1.76), acute renal failure (OR = 4.74; 95% CI = 3.46-6.48), respiratory failure (OR = 2.21; 95% CI = 1.23-3.98), endometritis (OR = 1.32; 95% CI = 1.02-1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38-4.62), uterine rupture (OR = 1.75; 95% CI = 1.21-2.54), hysterectomy (OR = 2.30; 95% CI = 1.66-3.18), peritonitis (OR = 2.86; 95% CI = 1.03-7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59-2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11-1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00-1.20), placenta previa (OR = 1.39; 95% CI = 1.06-1.84), multiple gestation (OR = 1.39; 95% CI = 1.23-1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42-10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24-25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09-1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50-0.76), previous CS (OR = 0.87; 95% CI = 0.82-0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31-0.86) conferred some protective effect against it.

CONCLUSION

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

TPM4 influences the initiation and progression of gastric cancer by modulating ferroptosis via SCD1

Gastric cancer (GC) is a deadly disease with poor prognosis and few treatment options. Tropomyosin 4 (TPM4) is an actin-binding protein that stabilizes the cytoskeleton of cells and has an unclear role in GC. This study aimed to elucidate the role and underlying mechanisms of TPM4 in GC pathogenesis. The expression and diagnostic and prognostic value of TPM4 in GC were analyzed using bioinformatics. A nomogram based on TPM4 expression was created and validated with an external cohort. TPM4-knockdown GC cells and xenograft models in nude mice were used to study the function of TPM4 in vitro and in vivo. Proteomic and rescue experiments confirmed the regulatory effect of TPM4 on stearoyl-CoA desaturase 1 (SCD1) in GC. Immunohistochemistry verified the expression and correlation of the TPM4 and SCD1 proteins in GC tissues. Our study identified TPM4 as an oncogene in GC, suggesting its potential diagnostic and prognostic value. The TPM4-based nomogram showed potential prognostic value for clinical use. TPM4 knockdown inhibited GC cell proliferation, induced ferroptosis, and slowed tumor growth in vivo, which is achieved by inhibiting SCD1 expression. Immunohistochemical analysis of GC tissues revealed elevated expression levels of both TPM4 and SCD1 proteins, with a positive correlation observed between their expression. TPM4 is a promising target for new diagnostic, prognostic, and therapeutic strategies for GC. Downregulation of TPM4 inhibits GC cell growth and induces ferroptosis by suppressing SCD1 expression.

Analysis of the incidence of post-cholecystectomy diarrhea and its influencing factors in Hainan Province

BACKGROUND AND AIMS

Cholecystectomy is one of the most common surgical procedures for the treatment of diseases associated with gallstones, and the incidence of post-cholecystectomy diarrhea (PCD) has attracted attention in recent years. The aim of this study was to assess the prevalence of PCD in patients with gallstones and to analyze the factors influencing it.

METHODS

Between August 2022 and December 2024, there were 3385 cases of gallstones diagnosed by abdominal ultrasound or CT examination and laparoscopic cholecystectomy in tertiary hospitals in Hainan Province. All participants in this study were followed up by telephone within 1 year postoperatively and by telephone survey using a standardized questionnaire. The incidence of PCD was calculated, and the relevant components of the follow-up were analyzed by one-way and multifactorial logistic regression using SPSS 26.0 statistical software.

RESULTS

Four hundred seventy-nine patients (14.2%) developed PCD after undergoing laparoscopic cholecystectomy. Univariate analysis showed that age, BMI, dietary patterns, history of diabetes, alcohol consumption, gallstones and fatty liver disease were associated with the development of PCD ( P < 0.05). Binary logistic regression analysis showed that age (OR = 0.532, P = 0.010), BMI (OR = 40.615, P < 0.001), dietary patterns (OR = 0.635, P = 0.013), and history of diabetes (OR = 0.263, P < 0.001) were independent risk factors.

CONCLUSION

The incidence of PCD in Hainan Province is 14.2%. Over 50 years old, BMI, dietary pattern and history of diabetes were independent risk factors for the occurrence of PCD.

The concept of dynamic frailty: an exploratory study of the trajectory to postoperative mortality

BACKGROUND

Frailty is a heightened vulnerability to stress due to decreased physical and mental abilities. Preoperative frailty has been associated with poorer outcomes. However, frailty is not static, and those patients who eventually die appear to become more frail. Our hypothesis is in-patient, postoperative changes in frailty after major operations predicts the trajectory to postoperative discharge alive or in-hospital mortality.

STUDY DESIGN

The accumulating deficit model of frailty was used. Data from the medical records of patients who have undergone major operations were used to determine the mFI preoperatively, postoperative day 1, and day before discharge or death. Of the 1063 patients who met inclusion criteria, 50 patients with in-hospital postoperative death and 50 patients discharged alive were randomly selected.

RESULTS

Patients in the in-hospital mortality group had significantly greater median preoperative mFI scores than those in the discharged alive (0.178 vs. 0.115 p = 0.00009). This significant difference was present on postoperative day 1, while also increasing in margin (0.240 vs. 0.143, p < 0.00001). Median Pre-Post mFI differences were also significant between the two groups, with operations leading to in-hospital mortality experiencing a greater increase in mFI (0.06 vs. 0.01 p = 0.00019), and the day before death or discharge (0.276 vs. 0.014, p < 0.00001).

CONCLUSION

Preoperative mFI is a useful predictor of postoperative mortality. Moreover, worsening mFI score as early as day 1 and continued worsening scores throughout hospitalization are associated with a postoperative trajectory toward mortality. Recognition of worsening frailty may be helpful in identifying patients in need of early intervention.

Understanding therapeutic tolerance through a mathematical model of drug-induced resistance

There is growing recognition that phenotypic plasticity enables cancer cells to adapt to various environmental conditions. An example of this adaptability is the ability of an initially sensitive population of cancer cells to acquire resistance and persist in the presence of therapeutic agents. Understanding the implications of this drug-induced resistance is essential for predicting transient and long-term tumor dynamics subject to treatment. This paper introduces a mathematical model of drug-induced resistance which provides excellent fits to time-resolved in vitro experimental data. From observational data of total numbers of cells, the model unravels the relative proportions of sensitive and resistance subpopulations and quantifies their dynamics as a function of drug dose. The predictions are then validated using data on drug doses that were not used when fitting parameters. Optimal control techniques are then utilized to discover dosing strategies that could lead to better outcomes as quantified by lower total cell volume.

Digital Decision Support for Perioperative Care of Patients With Type 2 Diabetes: A Call to Action

Unlabelled

Type 2 diabetes mellitus affects over 500 million people globally, with 10%-20% requiring surgery. Patients with diabetes are at increased risk for perioperative complications, including prolonged hospital stays and higher mortality, primarily due to perioperative hyperglycemia. Managing blood glucose during the perioperative period is challenging, and conventional monitoring is often inadequate to detect rapid fluctuations. Clinical decision support systems (CDSS) are emerging tools to improve perioperative diabetes management by providing real-time glucose data and medication recommendations. This viewpoint examines the role of CDSS in perioperative diabetes care, highlighting their benefits and limitations. CDSS can help manage blood glucose more effectively, preventing both hyperglycemia and hypoglycemia. However, technical and integration challenges, along with clinician acceptance, remain significant barriers.

Association between long-term exposure to PM2.5 and thyroid nodules in school-aged children and adolescents: a cross-sectional study in Eastern China

BACKGROUND

Long-term exposure to particulate matter with aerodynamic diameter ≤ 2.5 μm (PM2.5) are linked to thyroid nodules in adults, but epidemiological evidence in children and adolescents and adjustments for key confounders are lacking. This study aimed to explore the association between long-term exposure to PM2.5 and the prevalence of thyroid nodules in school-aged children and adolescents.

METHODS

A cross-sectional study including 10,739 primary and junior high school students was conducted in Jiangsu Province, China, in 2021. Annual PM2.5 concentrations were estimated by a satellite based space-time model based on machine learning. Individual exposure concentrations were assigned according to the school addresses of the participants. High-resolution diagnostic ultrasound imaging was used to detect the thyroid nodules. After adjustment for covariates, the link between the two-year (2019-2020) average PM2.5 concentrations and thyroid nodules was estimated using a generalized linear mixed-effects model. The concentration-response (C-R) curves were smoothed using a restricted cubic spline function. Stratified analyses were performed to evaluate the modification effects of covariates on associations.

RESULTS

The average age of the 10,067 participants (51.9% boys) was 11 years, with a thyroid nodule prevalence of 30.5%. A non-linear positive correlation was found between the increase in prevalence of thyroid nodules and two-year average exposure concentration of PM2.5. The C-R relationship curve between thyroid nodules and PM2.5 had a J-shaped structure with a threshold value of 39.7 µg/m3. Following covariates adjustment, the odds ratio (OR) and 95% confidence interval (CI) linked to thyroid nodules were 1.515 (1.199, 1.915) for per standard deviation (SD) increase in two-year average PM2.5 concentrations (> 39.7 µg/m3). The sex-specific associations found among adults were not observed in our stratified analyses.

CONCLUSIONS

Our findings demonstrated that long-term exposure to PM2.5 was associated with a higher prevalence of thyroid nodules in children and adolescents. Strategies that consistently reduce PM2.5 pollution levels to ease the burden of non-communicable diseases have important public health implications.

Pulmonary and functional hallmarks after SARS-CoV-2 infection across three WHO severity level-groups: an observational study

Background

The manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection range from flu-like symptoms to severe lung disease. The consequences of this inflammatory process impact overall function, which can be detected through both short- to long-term assessments. This study aimed to assess the pulmonary functional and structural characteristics of post-SARS-CoV-2 infection in patients with mild/moderate, severe, and critical clinical presentations.

Methods

An observational, analytical, and cross-sectional study was conducted between 2020 and 2022, including participants with a confirmed diagnosis of coronavirus disease (COVID)-19, with mild/moderate (G1), severe (G2), and critical (G3) clinical presentations, all evaluated at least 3 months after acute infection. Spirometry, impulse oscillometry, fractional exhaled nitric oxide (FeNO), chest computed tomography, the 6-min walk test (6MWT), hand grip strength, maximum inspiratory pressure, and maximum expiratory pressure were assessed.

Results

We enrolled 210 participants aged 18-70 years, 32.6% of whom were male, with older age observed in G3. The participants were grouped as follows: G1 (42.3%), G2 (25.7%), and G3 (31.9%). Percentage of predicted X5 differed between G1 and G2, being higher in G1. The percentage of predicted forced vital capacity (FVC) according to the Global Lung Function Initiative and its z-score were higher in G1. The FVC by Pereira was lower in G3 compared to G1. The percentage of predicted forced expiratory volume in 1 s (FEV1) by Pereira was also lower in G3. The Tiffeneau (FEV1/FVC) index was different among groups, increasing with disease severity. The percentage of predicted forced expiratory flow rate at 25-75% (FEF25-75%) of the FVC and FeNO were both higher in G2 than G1. Chest computed tomography revealed the presence of interstitial abnormalities, associated with disease severity. The respiratory muscle strength evaluation showed an association between higher maximum expiratory pressure values in G3 compared to G1, but no association with maximum inspiratory pressure was observed. The 6MWT distance covered decreased with increasing severity, with a lower percentage of predicted values in G3 compared to G1. The right-hand grip strength was also lower in G3 compared to G1.

Conclusion

Alterations in pulmonary and functional markers were observed in post-COVID-19 evaluations, increasing with disease severity, as seen in G2 and G3. These findings highlight the complexity of post-COVID-19 functional assessments, given the long-term pulmonary sequelae and the consequent impairment of functional capacity.

Long-term outcome of prophylactic biosynthetic mesh reinforcement at the time of loop ileostomy reversal for colorectal cancer- results of a case-matched study

PURPOSE

Stoma site incisional hernia (SSIH) is a frequent complication following ileostomy closure but can be potentially decreased by prophylactic mesh reinforcement. The aim was to assess if the use of a slowly absorbable biosynthetic mesh at the time of ileostomy reversal could reduce the incidence of SSIH.

METHODS

Outcomes of consecutive patients receiving prophylactic biosynthetic mesh (poly-4-hydroxybutyrate Phasix®, BD) implantation at the time of ileostomy reversal for colorectal cancer were prospectively collected in the Club Hernie database. Outcomes were compared with those of matched patients from a historical cohort of patients undergoing ileostomy reversal without mesh augmentation.

RESULTS

A total of 100 patients underwent ileostomy reversal: 50 with biosynthetic mesh augmentation (mesh group) and 50 with standard fascial closure without mesh (control group). Mesh augmentation did not increase the operating time (mesh group 49.8 min vs. control group 60.5 min, p < 0.01), the incidence of surgical site infection (mesh group 4% vs. control group 6%, p = 1) or the length of hospital stay (mesh group 5 days vs. control group 6 days, p = 0.28). After a mean follow-up of 4 years, the rate of SSIH, diagnosed by CT scan, was significantly lower in the mesh group (mesh group 8% vs. control group 24%, p = 0.029).

CONCLUSION

Prophylactic use of a slowly absorbable biosynthetic mesh at the time of ileostomy reversal for colorectal cancer was safe and effective in reducing the rate of SSIH without increasing surgical site infection.

A Prospective Analysis of the Burden of Multi-Drug-Resistant Pathogens in Acute Appendicitis and Their Implication for Clinical Management

Background/Objectives: Appendicitis caused by multi-drug-resistant pathogens is associated with significant postoperative morbidity. However, prospective data on the microbial spectrum and its clinical impact remain limited. Methods: Adults with acute appendicitis undergoing surgery between April 2022 and July 2023 were prospectively enrolled at a single university-affiliated institution. Bacterial cultures from appendiceal and rectal swabs were analyzed, and clinical outcomes were assessed. A telephone follow-up was conducted 30 days postoperatively. Results: A total of 105 patients were included. Multi-drug-resistant pathogens were identified in the appendiceal swabs of twenty-nine patients (27.6%), while six patients (5.7%) harbored multi-drug-resistant organisms (MDROs; according to the criteria of the CDC). Rectal swabs revealed MDROs in 11.4% of cases but showed a limited correlation with appendiceal samples, indicating that rectal colonization does not reliably predict the presence of MDROs in appendicitis. Patients with multi-drug-resistant infections had significantly higher postoperative complication rates (31% vs. 10.5%, p = 0.017), including more Clavien-Dindo grade 3 complications (17.2% vs. 2.6%, p = 0.007) and abdominal abscesses (10.3% vs. 1.3%, p = 0.03). These patients required more frequent postoperative antibiotic treatment (65.5% vs. 40.8%, p = 0.03) and therapy adjustments (37.9% vs. 15.8%, p = 0.02). Hospital stays were also prolonged in the multi-drug-resistant group (a median of 4 days and IQR of 5 days vs. a median of 3 days and IQR of 3 days; p = 0.03). Conclusions: Colonization with multi-drug-resistant pathogens in appendicitis is associated with worse clinical outcomes. The intraoperative microbiological analysis of appendiceal swabs in complicated cases may enable targeted antibiotic therapy, potentially shortening hospital stays, optimizing patient management and reducing healthcare costs.

Outcome prediction after emergency cholecystectomy: performance evaluation of the ACS-NSQIP surgical risk calculator and the 5-item modified frailty index

Pre-operative risk assessment tools and frailty scores are increasingly common due to the growing number of elderly, comorbid and frail patients. This study aims to assess the performance of the ACS-NSQIP-SRC (American College of Surgeons- National Surgical Quality Improvement Program- Surgical Risk Calculator) and the 5mFI (5-items modified Frailty Index) in predicting clinical outcomes after emergency cholecystectomy. This is a retrospective cohort study of patients with acute calculous cholecystitis admitted at our tertiary care center from 2018 to 2023. We evaluated discrimination, calibration, and accuracy of the ACS-NSQIP-SRC and 5mFI in predicting any complication, mortality, length of hospital stay (LOS), need for readmission and supported discharge (30-day follow-up). Among 365/642 patients who underwent surgery, the 5mFI showed poor discrimination for all outcomes but good overall accuracy in the prediction of a supported discharge. In 198 operated patients with available data for the ACS-NSQIP-SRC, it underestimated complications and need for readmission while overestimated the need for supported discharge. There was no concordance between predicted and observed LOS. Among 277/642 patients undergoing non-operative management, 2/3 were frail or mild frail and had a predicted rate of any unfavorable outcome after surgery between 0 and 20%, being 95% above the average risk of each outcome. Mortality couldn't be studied because no death was reported. ACS-NSQIP-SRC and 5mFI performance in predicting outcomes after emergency cholecystectomy for acute cholecystitis was poor. In the emergency cholecystectomy setting, the ACS-NSQIP-SRC may be less informative, and the 5mFI may be excessively simplistic by neglecting the multidimensional nature of frailty.

A comparative analysis of trauma-related mortality in South Korea using classification models

BACKGROUND

Reducing mortality among severe trauma patients requires the establishment of an effective emergency transportation system and the rapid transfer of patients to appropriate medical facilities. Machine learning offers significant potential to enhance the efficiency and quality of these emergency medical services.

METHODS

A retrospective secondary analysis was conducted using region-specific trauma survey data. The analysis focused on socio-economic characteristics, mechanisms of injury, injury severity, and variables indicating the effectiveness of the emergency medical system in optimizing machine learning algorithms for predicting severe patient transportation decisions.

RESULTS

Among the 8,769 patients with severe trauma, 7.2 % died in the hospital, with an average age of 50.06 years. The average injury severity score was 8.44, and the average time from accident reporting to arrival at the emergency medical facility was 55.39 min. The trend showed that as the level of the emergency medical institution increased, the patient transport time increased, while the mortality rate decreased. Additionally, XGBoost showed the best performance in mortality classification using a dataset sampled with SMOTE-ENN. Although the difference was minimal, undersampling slightly outperformed oversampling in the classification of emergency patients.

CONCLUSION

The treatment of emergency patients is influenced not only by transport time but also by the resources and staff levels of specialized emergency medical centers, which in turn affect survival rates. Furthermore, given the superior performance of composite sampling methods in analyzing imbalanced datasets, the importance of considering such imbalanced datasets in the analysis is evident.

Implementing sustainable practices to reduce wastage and costs in adenotonsillectomy

BACKGROUND

Surgical waste presents significant environmental and economic challenges in healthcare. Adenotonsillectomy, a common otolaryngological procedure, contributes to this issue. There is limited research on sustainability measures in adenotonsillectomy, and no studies have specifically identified waste reduction strategies for this operation in a general ENT unit. This study aimed to identify sustainable practices for waste reduction in adenotonsillectomy surgeries and quantify the extent of waste reduction in terms of weight and cost.

METHODS

The items opened and waste produced during adenotonsillectomies in a single institution were documented, including weights and costs. After reviewing the actual materials used by otolaryngologists and identifying potentially avoidable waste, a low-waste setup was designed. Waste weight and costs were evaluated post-implementation and compared with baseline values.

RESULTS

Several steps to reduce wastage in adenotonsillectomy surgeries were identified, including the elimination of surgical drapes and gowns. This resulted in a waste reduction of over 60%, with an average reduction in weight per case of 1.114 kg. The estimated reduction over 1 year for 294 cases was 327.52 kg. The mean reduction in material costs per case was $41.67, with an extrapolated annual savings of $12 250.98 for 294 cases.

CONCLUSION

Implementing sustainable practices in adenotonsillectomy surgeries can significantly reduce waste and healthcare facility cost, providing both environmental and economic benefits.

Developing A Model to Predict Major Bleeding Among Hospitalized Patients Undergoing Therapeutic Plasma Exchange

Although therapeutic plasma exchange (TPE) can be associated with bleeding, there are currently no known strategies to reliably predict bleeding risk. This study developed a TPE bleeding risk prediction model for hospitalized patients. To develop the prediction model, we undertook a secondary analysis of public use files from the Recipient Epidemiology and Donor Evaluation Study-III. First, we used a literature review to identify potential predictors. Second, we used Multiple Imputation by Chained Equations to impute variables with < 30% missing data. Third, we performed a 10-fold Cross-Validated Least Absolute Shrinkage and Selection Operator to optimize variable selection. Finally, we fitted a logistic regression model. The model identified 10 unique predictors and seven interactions. Among those with the highest odds ratios (OR) were the following: > 10 TPE procedures and antiplatelet agents (OR 3.26); nephrogenic systemic sclerosis (OR 3.15); and intensive care unit stay (OR 3.08). Among those with the lowest OR were the following: albumin-only TPE (OR 0.50); male sex (OR 0.82); and heart failure (OR 0.85). The model indicated an acceptable performance with a C-statistic of 0.71 (95% CI 0.699-0.717). A model to predict bleeding risk among hospitalized patients undergoing TPE identified key predictors and interactions. Although the model achieved acceptable performance, future studies are needed to validate and operationalize it.

Nomogram for prediction of severe postoperative complications in elective hepato-pancreato-biliary surgery after COVID-19 breakthrough infection: A large multicenter study

BACKGROUND

Currently, there is a deficiency in a strong risk prediction framework for precisely evaluating the likelihood of severe postoperative complications in patients undergoing elective hepato-pancreato-biliary surgery subsequent to experiencing breakthrough infection of coronavirus disease 2019 (COVID-19). This study aimed to find factors predicting postoperative complications and construct an innovative nomogram to pinpoint patients who were susceptible to developing severe complications following breakthrough infection of COVID-19 after undergoing elective hepato-pancreato-biliary surgery.

METHODS

This multicenter retrospective cohort study included consecutive patients who underwent elective hepato-pancreato-biliary surgeries between January 3 and April 1, 2023 from four hospitals in China. All of these patients had experienced breakthrough infection of COVID-19 prior to their surgeries. Additionally, two groups of patients without preoperative COVID-19 infection were included as comparative controls. Surgical complications were meticulously documented and evaluated using the comprehensive complication index (CCI), which ranged from 0 (uneventful course) to 100 (death). A CCI value of 20.9 was identified as the threshold for defining severe complications.

RESULTS

Among 2636 patients who were included in this study, 873 were included in the reference group I, 941 in the reference group II, 389 in the internal cohort, and 433 in the external validation cohort. Multivariate logistic regression analysis revealed that completing a full course of COVID-19 vaccination > 6 months before surgery, undergoing surgery within 4 weeks of diagnosis of COVID-19 breakthrough infection, operation duration of 4 h or longer, cancer-related surgery, and major surgical procedures were significantly linked to a CCI > 20.9. A nomogram model was constructed utilizing CCI > 20.9 in the training cohort [area under the curve (AUC): 0.919, 95% confidence interval (CI): 0.881-0.957], the internal validation cohort (AUC: 0.910, 95% CI: 0.847-0.973), and the external validation cohort (AUC: 0.841, 95% CI: 0.799-0.883). The calibration curve for the probability of CCI > 20.9 demonstrated good agreement between the predictions made by the nomogram and the actual observations.

CONCLUSIONS

The developed model holds significant potential in aiding clinicians with clinical decision-making and risk stratification for patients who have experienced breakthrough infection of COVID-19 prior to undergoing elective hepato-pancreato-biliary surgery.

The Effects of Perioperative Corticosteroids on Postoperative Complications After Pancreatoduodenectomy: A Debated Topic of Systematic Review and Meta-analysis

BACKGROUND

The intraoperative administration of corticosteroids has been shown to improve postoperative outcomes in patients undergoing surgery; however, the impact of corticosteroids on complications following pancreatoduodenectomy (PD) remains controversial.

OBJECTIVE

This study aimed to evaluate the efficacy of perioperative corticosteroids on postoperative complications after PD.

MATERIALS AND METHODS

A comprehensive search was conducted using the PubMed, Embase, and Web of Science databases for studies published prior to 1 July 2024. Of 7418 articles identified, a total of 5 studies were eligible for inclusion in this meta-analysis. The primary outcome was incidence of postoperative major complications (PMCs), while the additional outcomes were incidences of postoperative pancreatic fistulas (POPFs), infection, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), bile leakage, reoperation, and 30-day mortality. The study was registered in the PROSPERO database (CRD42024524936).

RESULTS

Finally, 5 studies involving 1449 patients (537 with corticosteroids and 912 without corticosteroids) were analyzed. Intraoperative corticosteroids were not associated with any improvement in PMCs (p = 0.41). The incidence of POPF (p = 0.12), infectious complications (p = 0.15), or DGE (p = 0.81) were not significantly different between the two groups. No obvious differences were found in the incidence of PPH (p = 0.42), bile leakage (p = 0.68), 30-day mortality (p = 0.99), or reoperation (p = 0.26).

CONCLUSION

Perioperative corticosteroids did not significantly demonstrate any protective advantage in terms of postoperative complications after PD. This finding may serve as a reference for the perioperative use of corticosteroids in pancreatic surgery. Well-designed clinical trials are warranted in the near future in order to provide high-level evidence.

Long-term accuracy of the National Emergency Laparotomy Audit risk score: Analysis of the impact of comorbidities on mortality 5 years after emergency laparotomy

BACKGROUND

The National Emergency Laparotomy Audit (NELA) risk prediction tool has demonstrated superiority in predicting 30-day mortality after emergency laparotomy (EL). The aim of our study was to evaluate the accuracy of NELA in calculating long-term (5 year) mortality and determine factors predicting long-term risk of death after EL.

METHODS

This retrospective cohort study included consecutive patients who underwent EL for any indication other than trauma between May 2012 and June 2017 at a large tertiary and academic teaching center. The primary outcome was all-cause postoperative mortality at 1 and 5 years. The c statistic (<1.0, excellent; <0.90, good; 0.80, fair; 0.70, poor) was used to assess accuracy of the NELA. Multivariable regression was used to identify independent risk factors for 5-year mortality after EL.

RESULTS

From a total of 758 patients, observed mortality continued to increase from 15.4% at 1 year up to 31.4% at 5 years. The NELA risk score accurately classified deceased patients at both 1 year ( c = 0.82; 95% confidence interval [CI], 0.78-0.85) and 5 years ( c = 0.82, 0.79-0.85) after EL. History of ascites (adjusted odds ratio [aOR], 3.3; 1.0-11.3; p = 0.048), chronic obstructive pulmonary disease (aOR, 1.9; 1.1-3.4; p = 0.030), congestive heart failure (aOR, 3.6; 1.2-11.5; p = 0.025), myocardial infarction (aOR, 2.6; 1.5-4.6; p = 0.001), and a new cancer diagnosis (aOR, 2.8; 1.7-4.8; p < 0.0001) were independent prognostic factors for death 5 years after EL.

CONCLUSION

Long-term prognosis after EL remains poor for at least 5 years postoperatively. The NELA score is accurately able to predict risk of death up to 5 years after EL. History of ascites, chronic obstructive pulmonary disease, congestive heart failure, myocardial infarction, and a new diagnosis of cancer were independent prognostic factors for long-term mortality after EL.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

The predictive value of postoperative intact parathyroid hormone for symptomatic hypocalcemia in older patients with thyroid cancer

Background

Due to the unique characteristics of older patients, they are more susceptible to develop symptomatic hypocalcemia (SH). This study aimed to analyze the potential relationship between the occurrence of SH and various indicators in older patients after thyroid cancer surgery, and to further discuss the predictive value of postoperative intact parathyroid hormone (iPTH) for SH, which can provide reference for clinical prevention and treatment of hypocalcemia in older patients.

Methods

A total of 137 older patients with thyroid cancer (≥60 years old) admitted to the Department of Thyroid Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School from January 2020 to December 2022 were selected. They were divided into the SH group and the asymptomatic group according to whether they developed SH. Relevant clinical data were collected and retrospectively analyzed. The measurement data of normal distribution were expressed by mean ± standard deviation (SD). Univariate and multivariate analyses were used to determine the risk factors for SH in older patients after thyroid cancer surgery. Statistical significance was set as P<0.05. Receiver operating characteristic (ROC) curve was constructed to study the predictive value of postoperative iPTH for SH occurrence in older patients with thyroid cancer.

Results

Among 137 older patients, 48 cases (35.04%) developed SH and 89 cases (64.96%) were asymptomatic. There were significant differences in preoperative iPTH (SH group: 7.00±5.25 pmol/L; asymptomatic group: 5.52±1.80 pmol/L; P=0.004) and postoperative iPTH (SH group: 0.69±0.95 pmol/L; asymptomatic group: 3.30±2.28 pmol/L; P<0.001) between the SH group and the asymptomatic group, with statistical significance (P<0.05). The area under the curve (AUC) of postoperative iPTH predicting SH occurrence in older patients with thyroid cancer was 0.855, cut-off was 0.5941 [95% confidence interval (CI): 0.794-0.917; sensitivity, 87.5%; specificity, 71.9%].

Conclusions

Postoperative iPTH is an independent risk factor for predicting SH in older patients with thyroid cancer. In order to avoid the occurrence of postoperative SH and reduce hospitalization costs and length, calcium supplementation should be given as soon as possible according to the level of postoperative iPTH.

Diagnostic efficacy of ultrasound and computed tomography for acute appendicitis: A single center retrospective study

The aim of this study was to evaluate the diagnostic efficacy of ultrasonography (US) and computed tomography (CT) examination for acute appendicitis (AA). A total of 41 patients with suspected AA were enrolled in this study. CT scan was performed in 24 patients, and US was performed in 17 patients. Both CT scan and US were performed in 7 patients. The primary outcomes were the performance characteristics (sensitivity, specificity) of US and CT in the patients with suspected AA. The secondary outcomes included the diagnostic accuracy of CT and US. By using US, 6 patients (35%) were incorrectly diagnosed and 2 other patients (12%) had equivocal results. By using CT as the primary diagnostic tool, 4 patients (17%) were misdiagnosed and 8 patients (33%) had equivocal results. Even if the equivocal results of CT and US were excluded from the calculation, the sensitivity and specificity of CT was 88% and 71% respectively, while the sensitivity and specificity of US was 73% and 50%, respectively. Although CT and US are believed to be reliable diagnostic tool to precisely diagnose AA. The rate of negative appendectomy still remains high. There is a need to develop a more accurate methods to diagnose AA, and therefore rate of negative appendectomy can be reduced.

A Greener Vascular Surgery: A Survey of Current Green Practices

BACKGROUND

Climate change is an environmental emergency. With health care systems contributing to 5% of carbon emissions globally, environmental sustainability is an important consideration when delivering surgical services. This survey aimed to understand current green practices across vascular centers.

METHODS

A survey on routine sustainable practices and the feasibility of implementing greener practices was developed between the Vascular and Endovascular Research Network and the Vascular Society of Great Britain and Ireland. The survey was delivered using the Qualtrics online survey tool and distributed through mailing lists and social media. The survey was open to completion by all vascular health care professionals internationally. Responses were collected between June 2, 2023, and September 15, 2023.

RESULTS

A total of 115 vascular health care professionals across 14 different countries responded. Disposable theater materials were used in 85% (98/115) of respondents' centers. Most centers used electronic patient records (investigation requests [76%, 85/112], observation charts [81%; 91/112], prescriptions [74%; 83/112]). Paper recycling policies were available in 52% (58/112) of respondents' centers. All the respondents agreed that vascular surgery can be greener. 80% (92/115) of respondents reported environmental sustainability was never discussed in departmental meetings and 24% (28/115) reported their department engaged with management to implement more sustainable practices. Barriers to change included finance (77%, 89/115), competing priorities (84%, 97/115), and lack of engagement (82%, 94/115).

CONCLUSION

This survey identified areas where vascular services could be more environmentally friendly, including reducing the use of disposable materials and improving recycling. Vascular health professionals are largely supportive of implementing changes to reduce the carbon footprint.

Malnutrition and perioperative nutritional rehabilitation in major operations

Background

Malnutrition is a potentially preventable risk factor for surgery. This systematic review examines nutritional management strategies aiming to enhance surgical outcomes.

Methods

A systematic search was conducted in PubMed for English-language studies published between July 1, 2004, and July 1, 2024, involving adult surgical patients. Study selection focused on four key themes: (1) nutritional screening and assessment, (2) preoperative nutritional therapy, (3) nutritional support in critically ill surgical patients, and (4) postoperative nutritional rehabilitation. Studies in non-surgical cohorts, letters, and case reports were excluded. Reference lists of relevant studies were manually screened for additional sources.

Results

Of 2763 studies identified, 251 met the inclusion criteria and 85 were added after manual screening, contributing to a total of 341 papers for the review. The prevalence of malnutrition varied widely by procedure, with the highest rates observed in pancreatic and esophagogastric operations. Preoperative malnutrition was strongly associated with increased postoperative complications, infections, prolonged hospital stay, and higher mortality. The Malnutrition Universal Screening Tool (MUST) was effective in identifying at-risk patients. Preoperative nutritional interventions, including dietitian-led counseling, oral supplementation, and enteral or parenteral nutrition, may reduce complications and improve outcomes. Critically ill patients benefited from structured enteral and parenteral strategies. Early postoperative nutrition within enhanced recovery after surgery (ERAS) protocols are linked to less complications and shorter hospital stay.

Conclusion

Malnutrition significantly impacts surgical outcomes, necessitating early identification and intervention. Standardized management is key to improving recovery and reducing complications. Future research should focus on refining diagnostic tools, assessing nutritional requirements, optimizing perioperative nutritional strategies, and establishing long-term nutritional follow-up guidelines for surgical patients.

Evaluation and Surgical Management of Pediatric Cutaneous Melanoma and Atypical Spitz and Non-Spitz Melanocytic Tumors (Melanocytomas): A Report From Children's Oncology Group

PURPOSE

The purpose of this study was to develop recommendations for the diagnostic evaluation and surgical management of cutaneous melanoma (CM) and atypical Spitz tumors (AST) and non-Spitz melanocytic tumors (melanocytomas) in pediatric (age 0-10 years) and adolescent (age 11-18 years) patients.

METHODS

A Children's Oncology Group-led panel with external, multidisciplinary CM specialists convened to develop recommendations on the basis of available data and expertise.

RESULTS

Thirty-three experts from multiple specialties (cutaneous/medical/surgical oncology, dermatology, and dermatopathology) established recommendations with supporting data from 87 peer-reviewed publications.

RECOMMENDATIONS

(1) Excisional biopsies with 1-3 mm margins should be performed when feasible for clinically suspicious melanocytic neoplasms. (2) Definitive surgical treatment for CM, including wide local excision and sentinel lymph node biopsy (SLNB), should follow National Comprehensive Cancer Network Guidelines in the absence of data from pediatric-specific surgery trials and/or cohort studies. (3) Accurate classification of ASTs as benign or malignant is more likely with immunohistochemistry and next-generation sequencing. (4) It may not be possible to classify some ASTs as likely/definitively benign or malignant after clinicopathologic and/or molecular correlation, and these Spitz tumors of uncertain malignant potential should be excised with 5 mm margins. (5) ASTs favored to be benign should be excised with 1- to 3-mm margins if transected on biopsy. (6) Re-excision is not necessary if the AST does not extend to the biopsy margin(s) when complete/excisional biopsy was performed. (7) SLNB should not be performed for Spitz tumors unless a diagnosis of CM is favored on clinicopathologic evaluation. (8) Non-Spitz melanocytomas have a presumed increased risk for progression to CM and should be excised with 1- to 3-mm margins if transected on biopsy. (9) Re-excision of non-Spitz melanocytomas is not necessary if the lesion is completely excised on biopsy.

Perioperative risk assessment for emergency general surgery in those with multimorbidity or frailty

PURPOSE OF REVIEW

This review explores advances in risk stratification tools and their applicability in identifying and managing high-risk emergency general surgery (EGS) patients.

RECENT FINDINGS

Traditional risk assessment tools have several limitations when applied to complex EGS patients as comorbidities are generally treated in a binary, linear and sequential fashion. Additionally, some tools are only usable in the postoperative period, and some require multidisciplinary involvement and are not suitable in an emergency setting. Frailty in particular - for which there are multiple calculators-maladaptively influences outcomes. Artificial intelligence tools, such as the machine-learning-based POTTER calculator, demonstrate superior performance by addressing nonlinear interactions among patient factors, offering a dynamic and more accurate approach to risk prediction.

SUMMARY

Integrating advanced, data-driven risk assessment tools into clinical practice can help identify and manage high-risk patients as well as forecast outcomes for EGS patients. Such tools are intended to trigger preoperative interventions as well as discussions that ensure goal-concordant care, align expectations with anticipated outcomes and support both facility and patient-relevant outcomes.

Systematic review on the use of artificial intelligence to identify anatomical structures during laparoscopic cholecystectomy: a tool towards the future

PURPOSE

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is a dreaded complication. Artificial intelligence (AI) has recently been introduced in surgery. This systematic review aims to investigate whether AI can guide surgeons in identifying anatomical structures to facilitate safer dissection during LC.

METHODS

Following PROSPERO registration CRD-42023478754, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic search of MEDLINE (via PubMed), EMBASE, and Web of Science databases was conducted.

RESULTS

Out of 2304 articles identified, twenty-five were included in the analysis. The mean average precision for biliary structures detection reported in the included studies reaches 98%. The mean intersection over union ranges from 0.5 to 0.7, and the mean Dice/F1 spatial correlation index was greater than 0.7/1. AI system provided a change in the annotations in 27% of the cases, and 70% of these shifts were considered safer changes. The contribution to preventing BDI was reported at 3.65/4.

CONCLUSIONS

Although studies on the use of AI during LC are few and very heterogeneous, AI has the potential to identify anatomical structures, thereby guiding surgeons towards safer LC procedures.

Epidemiological analysis of intra-abdominal infections in Italy from the Italian register of complicated intra-abdominal infections-the IRIS study: a prospective observational nationwide study

BACKGROUND

Intra-abdominal infections (IAIs) are common and severe surgical emergencies associated with high morbidity and mortality. In recent years, there has been a worldwide increase in antimicrobial resistance associated with intra-abdominal infections, responsible for a significant increase in mortality rates. To improve the quality of treatment, it is crucial to understand the underlying local epidemiology, clinical implications, and proper management of antimicrobial resistance, for both community- and hospital-acquired infections. The IRIS study (Italian Register of Complicated Intra-abdominal InfectionS) aims to investigate the epidemiology and initial management of complicated IAIs (cIAIs) in Italy.

MATERIAL AND METHOD

This is a prospective, observational, nationwide (Italy), multicentre study. approved by the coordinating centre ethic committee (Local Research Ethics Committee of Pisa (Prot n 56478//2019). All consecutively hospitalized patients (older than 16 years of age) with diagnosis of cIAIs undergoing surgery, interventional drainage or conservative treatment have been included.

RESULTS

4530 patients included from 23 different Italian hospitals. Community Acquired infection represented the 70.9% of all the cases. Among appendicitis, we found that 98.2% of the cases were community acquired (CA) and 1.8% Healthcare-associated (HA) infections. We observed that CA represented the 94.2% and HA 5.8% of Gastro Duodenal perforation cases. The majority of HA infections were represented by colonic perforation and diverticulitis (28.3%) followed by small bowel occlusion (19%) and intestinal ischemia (18%). 27.8% of patients presented in septic shock. Microbiological Samples were collected from 3208 (70.8%) patients. Among 3041 intrabdominal sample 48.8% resulted positive. The major pathogens involved in intra-abdominal infections were found to be E.coli (45.6%). During hospital stay, empiric antimicrobial therapy was administered in 78.4% of patients. Amoxicillin/clavulanate was the most common antibiotic used (in 30.1% appendicitis, 30% bowel occlusion, 30.5% of cholecystitis, 51% complicated abdominal wall hernia, 55% small bowel perforation) followed by piperacillin/tazobactam (13.3% colonic perforation and diverticulitis, 22.6% cholecystitis, 24.2% intestinal ischemia, 28.6% pancreatitis). Empiric antifungal therapy was administered in 2.6% of patients with no sign of sepsis, 3.1% of patients with clinical sign of sepsis and 4.1% of patients with septic shock. Azoles was administered in 49.2% of patients that received empiric antifungal therapy. The overall mortality rate was 5.13% (235/4350). 16.5% of patients required ICU (748/4350). In accordance with mortality, it is important to highlight that 35.7% of small bowel perforation, 27.6% of colonic perforation and diverticulitis, 25.6% of intestinal ischemia and 24.6% of gastroduodenal complications required ICU.

CONCLUSION

Antibiotic stewardship programs and correct antimicrobial and antimycotic prescription campaigns are necessary to ulteriorly improve the adequacy of drug usage and reduce the resistances burden. This will help in improving the care and the cure of the next generations.

Novel biological risk factors for 7-day postoperative kidney injury in elective major non-cardiac surgery: a retrospective observational study

INTRODUCTION

Few UK studies have explored the epidemiology of postoperative acute kidney injury after diverse types of elective major non-cardiac surgery. Fewer still have compared postoperative acute kidney injury risk factors with conditions such as peri-operative myocardial injury that might have similar pathophysiology. This study aimed to characterise postoperative acute kidney injury and its clinical consequences in elective major non-cardiac surgery, and to assess risk factors for postoperative acute kidney injury including those related to peri-operative myocardial injury.

METHODS

All elective major non-cardiac surgical episodes, occurring between 2015 and 2020, were identified retrospectively. Patients without measured peri-operative renal parameters were not studied. Our primary outcome was 7-day postoperative acute kidney injury rate, defined using Kidney Disease Improving Global Outcomes criteria. Multivariable logistic regression modelling was used to assess risk factors for postoperative acute kidney injury.

RESULTS

Postoperative acute kidney injury occurred in 1334/13,790 (9.7%) episodes, with 663 (49.7%) occurring on day 1. Postoperative acute kidney injury was associated with increased peri-operative complications (OR 1.8, 95%CI 1.6-2.1, p < 0.001), unanticipated critical care admissions (OR 2.4, 95%CI 1.6-3.5, p < 0.001) and in-hospital mortality (OR 8.0, 95%CI 5.1-12.5, p < 0.001). Independent risk factors for postoperative acute kidney injury include: raised creatinine; hypertension; anaemia; platelet: lymphocyte ratio; heart rate; male sex: renin-angiotensin-aldosterone system blockade; and intra-abdominal surgery.

DISCUSSION

Postoperative acute kidney injury is common and is associated with adverse outcomes. Prevalence peaks initially within the first 48 h, with a secondary rise seen from day 5 onwards, suggesting a different aetiology. It is determined by a combination of patient and surgical risk factors, with the former relating to physiological, rather than chronological, renal age. In common with peri-operative myocardial injury, postoperative acute kidney injury is independently associated with factors affecting autonomic tone and myeloid skewing.

Risk Prediction Models for Sentinel Node Positivity in Melanoma: A Systematic Review and Meta-Analysis

Importance

There is a need to identify the best performing risk prediction model for sentinel lymph node biopsy (SLNB) positivity in melanoma.

Objective

To comprehensively review the characteristics and discriminative performance of existing risk prediction models for SLNB positivity in melanoma.

Data Sources

Embase and MEDLINE were searched from inception to May 1, 2024, for English language articles.

Study Selection

All studies that either developed or validated a risk prediction model (defined as any calculator that combined more than 1 variable to provide a patient estimate for probability of melanoma SLNB positivity) with a corresponding measure of model discrimination were considered for inclusion by 2 reviewers, with disagreements adjudicated by a third reviewer.

Data Extraction and Synthesis

Data were extracted in duplicate according to Data Extraction for Systematic Reviews of Prediction Modeling Studies, Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Effects were pooled using random-effects meta-analysis.

Main Outcome and Measures

The primary outcome was the mean pooled C statistic. Heterogeneity was assessed using the I2 statistic.

Results

In total, 23 articles describing the development of 21 different risk prediction models for SLNB positivity, 20 external validations of 8 different risk prediction models, and 9 models that included sufficient information to obtain individualized patient risk estimates in routine preprocedural clinical practice were identified. Among all risk prediction models, the pooled weighted C statistic was 0.78 (95% CI, 0.74-0.81) with significant heterogeneity (I2 = 97.4%) that was not explained in meta-regression. The Memorial Sloan Kettering Cancer Center and Melanoma Institute of Australia models were most frequently externally validated with both having strong and comparable discriminative performance (pooled weighted C statistic, 0.73; 95% CI, 0.69-0.78 vs pooled weighted C statistic, 0.70; 95% CI, 0.66-0.74). Discrimination was not significantly different between models that included gene expression profiles (pooled C statistic, 0.83; 95% CI, 0.76-0.90) and those that only used clinicopathologic features (pooled C statistic, 0.77; 95% CI, 0.73-0.81) (P = .11).

Conclusions and Relevance

This systematic review and meta-analysis found several risk prediction models that have been externally validated with strong discriminative performance. Further research is needed to evaluate the associations of their implementation with preprocedural care.

Number, treatment, and mortality of paediatric pelvic ring fractures in two level 1 trauma centres in the Netherlands : a multicentre retrospective cohort study

Aims

Paediatric pelvic ring fractures are rare but severe injuries, presenting significant treatment challenges. This study aimed to analyze patient characteristics and explore trends in incidence, treatment methods, and mortality associated with these injuries.

Methods

This multicentre, retrospective cohort study analyzed paediatric patients (aged ≤ 18 years) with pelvic ring fractures treated between 2001 and 2021 at two level 1 trauma centres. Data on patient demographics, injury characteristics, treatment approaches, and outcomes were collected, and visual trend analysis was conducted to identify patterns.

Results

A total of 157 patients with pelvic ring fractures were included. The median age was 15 years (IQR 12 to 17), with 52% (n = 81) being female. Traffic accidents were the leading cause of injury, accounting for 68% of cases (n = 106). Concomitant injuries were observed in 83% of patients (n = 131). The one-year mortality rate was 11.5%, with 76% of deaths occurring within 48 hours of admission, primarily due to traumatic brain injury (53%). Most patients (60%) were treated nonoperatively, while 48% of surgically treated patients underwent internal fixation without prior external fixation. Visual trend analysis revealed an increase in the absolute number of paediatric pelvic ring fractures over time, though no significant shift towards surgical treatment was observed. Among surgically treated patients, there was a trend towards open reduction and internal fixation rather than external fixation as definitive treatment. Nonoperative treatment was more common in children (69%) than in adolescents (55%). For surgical cases, external fixation was preferred in children (44%), while ORIF was more common in adolescents (53%).

Conclusion

The incidence of paediatric pelvic ring fractures has increased over time, with a high mortality rate largely attributable to severe neurotrauma. There has been a shift towards surgical treatment without prior external fixation, with differences noted in the treatment approaches between children and adolescents, particularly in surgical fixation methods.

Machine learning for the rElapse risk eValuation in acute biliary pancreatitis: The deep learning MINERVA study protocol

BACKGROUND

Mild acute biliary pancreatitis (MABP) presents significant clinical and economic challenges due to its potential for relapse. Current guidelines advocate for early cholecystectomy (EC) during the same hospital admission to prevent recurrent acute pancreatitis (RAP). Despite these recommendations, implementation in clinical practice varies, highlighting the need for reliable and accessible predictive tools. The MINERVA study aims to develop and validate a machine learning (ML) model to predict the risk of RAP (at 30, 60, 90 days, and at 1-year) in MABP patients, enhancing decision-making processes.

METHODS

The MINERVA study will be conducted across multiple academic and community hospitals in Italy. Adult patients with a clinical diagnosis of MABP, in accordance with the revised Atlanta Criteria, who have not undergone EC during index admission will be included. Exclusion criteria encompass non-biliary aetiology, severe pancreatitis, and the inability to provide informed consent. The study involves both retrospective data from the MANCTRA-1 study and prospective data collection. Data will be captured using REDCap. The ML model will utilise convolutional neural networks (CNN) for feature extraction and risk prediction. The model includes the following steps: the spatial transformation of variables using kernel Principal Component Analysis (kPCA), the creation of 2D images from transformed data, the application of convolutional filters, max-pooling, flattening, and final risk prediction via a fully connected layer. Performance metrics such as accuracy, precision, recall, and area under the ROC curve (AUC) will be used to evaluate the model.

DISCUSSION

The MINERVA study aims to address the specific gap in predicting RAP risk in MABP patients by leveraging advanced ML techniques. By incorporating a wide range of clinical and demographic variables, the MINERVA score aims to provide a reliable, cost-effective, and accessible tool for healthcare professionals. The project emphasises the practical application of AI in clinical settings, potentially reducing the incidence of RAP and associated healthcare costs.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT06124989.

Evidence of 18 F-FDG Utility in Rare Case of Metastatic Anal Melanoma With Prolonged Survival

ABSTRACT

A 43-year-old woman presented with an anorectal mass at which time excision was performed, and biopsy revealed anorectal mucosal melanoma (AM), anal subtype. Postexcision, 18 F-FDG PET/CT identified residual melanoma, confirmed on biopsy. Recurrence was monitored every 3 months using 18 F-FDG, which identified a perirectal lymph node 2.5 years later positive for metastatic melanoma. Given the rarity of AM and often delayed diagnosis, patients often present with metastases, resulting in poor prognosis. This unique case of metastatic AM with prolonged survival of 7 years to date supports the implementation of 18 F-FDG in the diagnostics and monitoring of AM.