Epidemiologic characteristics of 22,086 patients discharged from the Department of Orthopaedic Trauma at a military hospital between 2013 and 2022: a retrospective real-world study

BACKGROUND

To analyse the epidemiological characteristics of orthopaedic trauma patients and thereby optimize healthcare resource allocation and improve treatment efficiency.

MATERIALS AND METHODS

Relying on the hospital information system (HIS) database, we retrospectively analysed the epidemiological characteristics of orthopaedic trauma inpatients in our hospital between 2013 and 2022, including patient demographic information, causes of injury, location of injury and hospitalization costs.

RESULTS

The median age of the patients was 36 (26-47) years old; the age stratification of the patients was highest in the proportion of patients aged 40-50 years old (29.23%); hypertension was the most common among the patients' comorbidities (1.29%); patients' occupation was highest in heavy labourers such as farmers and workers, about 63.04% (n = 13923); patients' admissions were mainly in the form of emergencies (n = 16875, 76.41%); and patients' median hospitalization time was 7 (5, 12) days. The highest percentage of the cause of injury was due to exposure to inanimate mechanical forces (75.4%), followed by falls (16.14%) and traffic accidents (6.49%). The highest percentage of cause of injury in all age groups was due to inanimate mechanical force, and the percentage of patients with falls increased with age, and there was a positive correlation between age groups and the percentage of patients with falls (r = 0.964, p < 0.01). The highest percentage of patients with injuries to the upper extremities was about 74%. The distribution of injury sites in all age groups was highest in the upper extremities. Age was positively correlated with trunk injuries (r = 0.469, p = 0.203). The median hospitalization cost for patients over a 10-year period was approximately $1,100.

CONCLUSIONS

By analysing the epidemiological characteristics of patients, a general profile of local orthopaedic trauma patients was established, which can help in the development of disease prevention and interventions.

Comparative outcomes of laparoscopic and open surgery in inflammatory bowel disease in pediatric and young adult patients: a systematic review and meta-analysis

BACKGROUND

Pediatric inflammatory bowel disease (IBD), encompassing Crohn's disease, ulcerative colitis, and indeterminate colitis, often necessitates surgical intervention in cases of severe or refractory disease. Although biologic therapies have significantly reduced the need for surgery, operative management remains essential for certain patients. The choice between laparoscopic (laparoscopy group [LG]) and open conventional surgery (open group [OG]) continues to be a subject of debate. This meta-analysis aimed to compare the postoperative outcomes of LG and OG in pediatric patients with IBD.

METHODS

We conducted a meta-analysis of observational studies comparing LG and OG outcomes in pediatric patients with IBD. Key outcomes analyzed included major and minor postoperative complications, reoperations, readmissions, operative time, and length of hospital stay.

RESULTS

Seven studies met the inclusion criteria, analyzing 3417 patients, with 1399 (41%) undergoing OG and 2018 (59%) undergoing LG. Our analysis revealed no significant differences in major postoperative complications, reoperation, and readmissions between LG and OG (P = .114, P = .082, and P = .641, respectively). However, LG was associated with shorter hospital stays (6.04 vs 8.35 days; P < .05). Conversions from LG to open surgery amounted to a total of 153 (7.57%). Open surgery had a significantly shorter operative time (173.8 vs 195.5 min; P = .005).

CONCLUSION

Both laparoscopic and open conventional surgeries are safe, effective, and reliable in managing pediatric IBD. Although open surgery offers shorter operative times, laparoscopy reduces hospital stay and minor postoperative complications. The choice of approach depends on the surgeon's experience and patient-specific factors.

Frailty is a prognostic marker of mortality and sepsis in patients ≥ 70 years with acute left-sided colonic diverticulitis

BACKGROUND

Acute left-sided colonic diverticulitis (ALCD) has a more complicated course in older patients. Rather than age, frailty may be crucial in ALCD prognosis in this heterogeneous population. This study aims to define the influence of the Clinical Frailty Scale (CFS) on mortality and clinical outcomes in patients aged 70 or older with ALCD.

METHODS

All patients aged ≥ 70 years admitted to the emergency department for ALCD between January 2018 and December 2022 were included. Frailty was assessed through the CFS, and three groups of patients were identified accordingly: non-frail patients (CFS 1-3); moderately frail patients (CFS 4-6); and severely frail patients (CFS 7-9). The endpoints were: 30-day mortality, sepsis onset, 30-day readmission, and length of hospital stay (LOS).

RESULTS

A total of 1127 patients were enrolled. Severely frail patients had a significantly higher rate of sepsis onset, mortality, and longer LOS at univariate analysis. Higher CFS scores were significantly associated with mortality, both as a continuous (OR 1.42) and discrete variable (OR 12.47), and sepsis, both as a continuous (OR 1.5) and discrete variable (OR 6.52) at multivariate analysis.

CONCLUSION

A higher CFS score, rather than age, is associated with higher rates of mortality, sepsis, and longer LOS. After adjusting for covariates, higher CFS scores were significantly associated with increased risk of 30-day mortality and sepsis. A comprehensive frailty assessment using the CFS should be considered to predict the need for closer monitoring and guiding appropriate care goals for older patients.

Risk factors and outcomes of Clostridioides difficile infection in patients with colorectal cancer: critical perspective in management

Colorectal cancer (CRC) ranks as the third most prevalent cancer worldwide, causing a serious threat to global health and social burden. Clostridioides difficile infection (CDI) is one of the most important nosocomial infections and has a higher incidence in cancerous population compared with non-cancerous cases. Different risk factors, including gut microbiota dysbiosis, extensive surgery, chemotherapy, prolonged hospitalization, and antimicrobial therapy, compromise host defenses against CDI and contribute to cancer patients' susceptibility to this infection. The emergence of CDI in patients with CRC creates conditions for therapy escalation and prolonged hospitalization, highlighting the need for correct and effective CDI management in these patients. Here, common risk factors associated with CDI in patients with CRC are discussed. In addition, different available techniques for the prevention, detection, and treatment of CDI with the lowest impact on gut microbiota diversity are summarized. This review aims to improve the understanding of the interplay between CDI and CRC and provide new insights into restoring and maintaining gut microbiota balance during CDI management in patients with CRC.

Source control in intra-abdominal infections: What you need to know

ABSTRACT

Providing optimal source control (SC) for intra-abdominal sepsis (IAS) is a critically important surgical principle, yet one that remains nebulous in terms of strict definitions and required conduct. The entire concept of SC has evolved in the last decades. Contemporary SC is not only surgical but also embraces minimally invasive percutaneous and medical therapies. We propose that adequate SC has evolved from the mere anatomical control of enteric leakage, cleansing of obvious contaminants and necrosis, to a more comprehensive anatomo-phyiological-biochemical model. While any breaches in the integrity of the gastrointestinal tract should be addressed urgently, SC should ultimately aim to control the generation and propagation of systemic biomediators, bacterial toxins, and toxic catabolites that perpetuate multisystem organ failure and death. Much urgently needs to be learned to understand and hopefully mitigate the dysbiotic influences of IAS on the human microbiome. Finally, the therapy offered should always be individualized, recognizing patient's unique pathophysiology, clinical condition, comorbidities, and predeclared preferences regarding invasive therapies and life-support.

Prophylactic drain placement after emergency general surgery procedures? A scoping review of the literature challenging common practice

BACKGROUND

This scoping review aims to map the existing literature on the use of prophylactic drainage (PD) after Emergency General Surgery procedures (EGS) and to change the current practice according to evidence.

METHODOLOGY

Data from an exhaustive literature search conducted across Embase (Ovid), Medline(R) ALL (Ovid), Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials was summarized. Literature published between January 2013 and December 2024 was included.

RESULTS

Most studies found better outcomes for the no-drain group. Implementing a drain after EGS procedures potentially increases hospital stays, postoperative pain, and surgical site infection rates. For conditions such as peritonitis and perforated ulcers, only a few studies were available, with some showing benefits of PD.

CONCLUSION

For some conditions, like colorectal emergencies, there is a scarcity of evidence. The outcomes suggest that PD is not recommended in most EGS cases. In high-risk cases, there are some reports on improved outcomes for PD use. Further research is imperative to create science-based clinical guidelines, especially for less-researched conditions.

Outcomes and Cost of Major Liver Resection Using Combined LigaSure and Stapler: A Propensity Score Matching Study

Background: Bile leakage remains a significant challenge following major liver resection, with potential for improvement depending on the transection technique used. In this study, we aimed to evaluate the effectiveness of our hybrid resection technique-utilizing both LigaSure and stapler devices-in reducing bile leakage after major liver resection compared to our conventional stapler-only technique. As a secondary aim, we compared overall morbidity, costs, and reimbursements. Method: Patients who underwent major hepatectomy without biliary reconstruction using either the hybrid or stapler technique between August 2014 and December 2021 were included in the study. Propensity score matching was performed using a one-to-two algorithm. Perioperative data, bile leakage rates, and cost and reimbursement information based on the diagnosis-related group (DRG) system were analyzed. Results: In total, data from 492 patients were evaluated (hybrid = 152; stapler = 340). After one-to-two propensity score matching, the operation time was significantly longer in the hybrid group (p = 0.005). A cost analysis showed no significant difference in total operative costs between the two techniques (p = 0.092). However, the hybrid group had a significantly lower rate of bile leakage (p = 0.002), as well as shorter intensive care unit (ICU) and overall hospital stays (p = 0.034 and p = 0.007, respectively). Consequently, ICU and ward costs were significantly lower in the hybrid group (p = 0.024 and p = 0.014, respectively) compared to the stapler group. The financial difference calculated as DRG reimbursement minus costs was two-fold higher in the hybrid group (p = 0.02). Conclusions: Although the hybrid technique resulted in a longer operating time, it proved superior to the stapler technique in reducing postoperative bile leakage and shortening ICU and hospital stays. Furthermore, the use of the hybrid technique was more cost efficient and resulted in a greater positive financial margin.

Significant Alterations of Colorectal Cancer Care in the COVID-19 Pandemic With High Adherence to Quality Criteria in German Cancer Centers (CC) ‒ Data From the AIO CancerCOVID Consortium (AIO-YMO/KRK 520/ass)

BACKGROUND

Colorectal cancer (CRC) remains a leading cause of death despite notable advancements through guideline-based management. We present data on changes of CRC care during the COVID-19 pandemic in Germany.

METHODS

Retrospective data from 22 AIO CCs and an academic Institute of Pathology compared the first (fw, 03-05.2020) and second wave (sw, 11-12.2020) of the pandemic with corresponding 2019 periods. Parameters were: number of cases diagnosed, age, sex, tumor stage, surgical procedures, quality criteria of CRC care (presentation in multidisciplinary tumor boards (MTB), psychological or social consultation), number of precancerous and malignant colorectal lesions (CRL). Data points were compared as mean values with confidence intervals estimated according to Clopper and Pearson (1934). Hypothesis tests were conducted using Poisson regression models that included interaction terms (year*sex or year*age over70). Statistical significance was considered at P < .05.

RESULTS

A total of 4316 cases diagnosed (AIO CC) revealed a substantial reduction (fw -20.58%; sw -23.48%). Hypothesis test showed a significant decline in incidence due to the fw and sw of the pandemic. Quality criteria of cancer care remained stable except for trial participation. Analysis from 60,695 CRL detected a decrease in precancerous (fw: -16 %/sw: -4 %) and malignant (fw: -18 %) lesions while malignant CRL increased in the sw (+8 %). Hypothesis test revealed a significant decline only for the fw 2020 and detected age > 70 as independent risk factor in both waves.

CONCLUSION

We detected substantial alterations in cancer care during the pandemic, including detected precancerous CRL. CCs showed high resilience in quality criteria for CRC care.

The role of inflammatory parameters in predicting acute complicated diverticulitis

AIM

Acute diverticulitis is an inflammatory process associated with pericolonic inflammation involving one or more colonic diverticula and is usually classified as uncomplicated or complicated.

METHOD

This multicenter study retrospectively examined the data of 135 patients who received inpatient treatment for diverticulitis in two tertiary hospitals. Some inflammation scores were calculated with the data obtained from the patients' Complete blood count(CBC) and biochemical laboratory results, and the power of these scores in predicting complicated diverticulitis was examined.

RESULTS

A total of 135 patients (57 men and 78 women) were included in this study. In the ROC analysis performed to evaluate the effectiveness of predicting complications, the CRP/Albumin(CAR) score was found to be significant (AUC: 0.762, p = 0.001). For a cutoff value > 0.25, CAR predicted complications with 73% sensitivity and 76% specificity (AUC: 0.762, p = 0.001).

CONCLUSION

Determining the severity of the disease by differentiating complicated from uncomplicated cases will contribute to reducing hospital stay times and related costs. Our study showed that CAR score can be used as a reliable, inexpensive, and rapid marker for predicting complicated diverticulitis in acute diverticulitis.

Measurement of adipose body composition using an artificial intelligence-based CT Protocol and its association with severe acute pancreatitis in hospitalized patients

BACKGROUND/OBJECTIVES

The clinical utility of body composition in predicting the severity of acute pancreatitis (AP) remains unclear. We aimed to measure body composition using artificial intelligence (AI) to predict severe AP in hospitalized patients.

METHODS

We performed a retrospective study of patients hospitalized with AP at three tertiary care centers in 2018. Patients with computer tomography (CT) imaging of the abdomen at admission were included. A fully automated and validated abdominal segmentation algorithm was used for body composition analysis. The primary outcome was severe AP, defined as having persistent single- or multi-organ failure as per the revised Atlanta classification.

RESULTS

352 patients were included. Severe AP occurred in 35 patients (9.9%). In multivariable analysis, adjusting for male sex and first episode of AP, intermuscular adipose tissue (IMAT) was associated with severe AP, OR = 1.06 per 5 cm2, p = 0.0207. Subcutaneous adipose tissue (SAT) area approached significance, OR = 1.05, p = 0.17. Neither visceral adipose tissue (VAT) nor skeletal muscle (SM) was associated with severe AP. In obese patients, a higher SM was associated with severe AP in unadjusted analysis (86.7 vs 75.1 and 70.3 cm2 in moderate and mild, respectively p = 0.009).

CONCLUSION

In this multi-site retrospective study using AI to measure body composition, we found elevated IMAT to be associated with severe AP. Although SAT was non-significant for severe AP, it approached statistical significance. Neither VAT nor SM were significant. Further research in larger prospective studies may be beneficial.

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.

SAGES white paper on antibiotic omission in the management of acute uncomplicated diverticulitis: why, when, who, and most importantly, how

BACKGROUND

Historically, the management of acute uncomplicated diverticulitis was centered on antibiotics. However, modern theories regarding the pathogenesis of diverticulitis have challenged the notion that antibiotics are necessary in all cases. Despite major reform in many societal guidelines, the adoption of non-antibiotic therapy for uncomplicated diverticulitis has been limited, especially in North America. The purpose of this SAGES White Paper was to review the available evidence on antibiotic omission in uncomplicated diverticulitis and to explore methods of safe implementation.

METHODS

A task force within the SAGES Colorectal Surgery Committee was formed to work on this White Paper. The committee and its leadership approved an outline that would focus on the following topics: (1) Defining the problem with unnecessary antibiotic exposure; (2) Evaluating the evidence on antibiotic omission in uncomplicated diverticulitis; (3) Identifying the appropriate patient for antibiotic omission; (4) Outlining how to counsel patients who are treated without antibiotics; (5) Reviewing methods to safely implement this practice in both the hospital and community setting. These topics were divided up among members of the task force who performed a structured literature search in preparation for their assignments.

RESULTS

Antibiotics are associated with several patient and societal adverse effects, including the rising problem of antimicrobial resistance. Randomized controlled trials have demonstrated no superiority to the routine administration of antibiotics in acute uncomplicated diverticulitis. Appropriate patients for antibiotic omission include those who are immunocompetent, non-septic, and have mild symptoms/disease severity on imaging. Existing frameworks for the safe implementation of new practices can be referenced to help increase adoption of non-antibiotic therapy.

CONCLUSION

The existing body of evidence supports antibiotic omission in appropriate cases of acute uncomplicated diverticulitis. In order to increase the widespread adoption of this practice, buy-in from key stakeholders (both healthcare professionals and patients) is necessary.

Outcomes After Elective Versus Emergency Resection for Right-Sided Colon Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Previous studies reported similar complication rates, including anastomotic leakage, after elective and emergency surgery for right-sided colon cancer. This led to the consensus that emergency resection with primary anastomosis is safe. However, recent evidence suggests higher complication rates after emergency surgery, indicating that alternative strategies, such as a bridge to surgery, may be more suitable.

OBJECTIVE

To assess whether complication rates, particularly anastomotic leakage, are higher after emergency resections compared to elective resections in patients with right-sided colon cancer.

DESIGN

A retrospective cohort study using data from the Dutch ColoRectal Audit from 2010 to 2019.

SETTINGS

Nationwide data from hospitals across the Netherlands.

PATIENTS

Patients who underwent resection for right-sided colon cancer (n = 5056 emergency resections matched 1:1 to elective resections using propensity score matching).

MAIN OUTCOME MEASURES

Incidence of anastomotic leakage, 90-day complication rates, and mortality rates after elective versus emergency surgery for right-sided colon cancer.

RESULTS

After matching, no significant baseline differences remained. There was no significant difference in anastomotic leakage rates. However, the mortality rate was twice as high in the emergency group (9.4% vs 4.2%, p < 0.001), and the 90-day complication rate was also higher (41.7% vs 33.0%, p < 0.001).

LIMITATIONS

Minimal missing data were handled with multiple imputation. Although propensity score matching was used, bias from unknown confounders may persist. The emergency group included more high-risk patients, potentially influencing outcomes.

CONCLUSIONS

Emergency resections for right-sided colon cancer are associated with higher complication and mortality rates compared to elective surgery. A bridge-to-surgery approach could reduce these risks by converting emergency cases to elective procedures. Further research is needed to validate these findings. See Video Abstract.

RESULTADOS TRAS LA RESECCIN ELECTIVA FRENTE A LA RESECCIN DE EMERGENCIA PARA CNCER DE COLON DEL LADO DERECHO UN ANLISIS DE PUNTUACIN DE PROPENSIN COINCIDENTE

ANTECEDENTES:Estudios previos informaron tasas de complicaciones similares, incluida la fuga anastomótica, después de una cirugía electiva y de emergencia para el cáncer de colon del lado derecho. Esto llevó al consenso de que la resección de emergencia con anastomosis primaria es segura. Sin embargo, evidencia reciente sugiere tasas de complicaciones más altas después de la cirugía de emergencia, lo que indica que las estrategias alternativas, como un puente a la cirugía, pueden ser más adecuadas.OBJETIVO:Evaluar si las tasas de complicaciones, en particular la fuga anastomótica, son más altas después de las resecciones de emergencia en comparación con las resecciones electivas en pacientes con cáncer de colon del lado derecho.DISEÑO:Un estudio de cohorte retrospectivo que utiliza datos de la Dutch ColoRectal Audit de 2010 a 2019.ESCENARIO:Datos a nivel nacional de hospitales de los Países Bajos.PACIENTES:Pacientes que se sometieron a una resección por cáncer de colon del lado derecho (n = 5056 resecciones de emergencia emparejadas 1:1 con resecciones electivas mediante emparejamiento por puntaje de propensión).PRINCIPALES MEDIDAS DE VALORACIÓN:Incidencia de fuga anastomótica, tasas de complicaciones a los 90 días y tasas de mortalidad después de cirugía electiva versus cirugía de emergencia para cáncer de colon del lado derecho.RESULTADOS:Después del emparejamiento, no se mantuvieron diferencias significativas al inicio. No hubo diferencias significativas en las tasas de fuga anastomótica. Sin embargo, la tasa de mortalidad fue dos veces más alta en el grupo de emergencia (9,4% frente a 4,2%, p < 0,001) y la tasa de complicaciones a los 90 días también fue mayor (41,7% frente a 33,0%, p < 0,001).LIMITACIONES:Los datos faltantes mínimos se manejaron con imputación múltiple. Si bien se utilizó el emparejamiento por puntaje de propensión, puede persistir el sesgo de factores de confusión desconocidos. El grupo de emergencia incluyó más pacientes de alto riesgo, lo que potencialmente influyó en los resultados.CONCLUSIONES:Las resecciones de emergencia para cáncer de colon del lado derecho se asocian con mayores tasas de complicaciones y mortalidad en comparación con la cirugía electiva. Un enfoque de puente a la cirugia podría reducir estos riesgos al convertir los casos de urgencia en procedimientos electivos. Se necesitan más investigaciones para validar estos hallazgos. (Traducción--Ingrid Melo).

Successful treatment with decompressive laparotomy for abdominal compartment syndrome induced by asparaginase-associated pancreatitis in a pediatric patient with acute lymphoblastic leukemia: a case report

Background

Asparaginase (ASP) has significantly improved the complete remission rate and long-term event-free survival in children with acute lymphoblastic leukemia (ALL). Asparaginase-associated pancreatitis (AAP) is a potentially toxic side effect of ASP, which may even lead to fatal abdominal compartment syndrome (ACS) in extreme cases. Currently, there is no consensus on the indications for decompressive laparotomy (DL), including when to initiate it, what criteria to use for decision-making, or how to perform the procedure. Moreover, available research data remain limited.

Case Description

We present a case of a 2-year-old boy with ALL who developed ACS, a fatal complication of severe acute pancreatitis (SAP) following treatment with pegaspargase (PEG-ASP). Massive transfusion stabilized his hemodynamics and intraluminal contents were evacuated, yet his symptoms progressed. Consequently, the patient underwent DL and continuous venovenous hemodiafiltration (CVVHDF) with ultrafiltration. Postoperative complications including enteroatmospheric fistulas and abdominal abscesses were gradually corrected by negative-pressure wound therapy (NPWT). The boy was discharged from the intensive care unit (ICU) on the 93rd day after hospital admission. During follow-up, the child's abdominal symptoms gradually improved, and bridging therapy with blinatumomab was administered.

Conclusions

In this case, a pediatric ALL patient developed life-threatening complications following PEG-ASP administration, which were ultimately successfully managed through multidisciplinary intervention. When pediatric hematology-oncology patients develop ACS, clinicians should carefully evaluate the oncological context and thoroughly assess the risks of surgical versus conservative management for this potentially fatal condition. Optimal timing of surgical intervention combined with advanced perioperative care is critical for achieving favorable outcomes. We strongly recommend conducting high-quality clinical research to establish evidence-based treatment guidelines.

Surveillance and follow-up in acute diverticulitis with pericolic free gas (ADiFas II): an age-specific analysis

The objective of this study was to examine the differences in clinical presentation and complications during the first year of follow-up in patients who experienced an episode of acute diverticulitis (AD) with pericolic free gas, comparing outcomes across different age groups. A prospective subanalysis was conducted on a cohort from the ADiFAS study, which originally included 1099 patients. After excluding 289 patients who did not meet the inclusion criteria, 810 patients remained for analysis. From this cohort, 330 patients with AD and pericolic free gas were selected using propensity score matching and divided into two age groups: < 65 years and ≥ 65 years. The groups were matched based on sex, BMI, diabetes mellitus (DM), cardiovascular disease, previous episodes of AD, and the presence of free fluid on CT scan. Data were assessed for Hinchey classification, surgical procedures, complications, and the frequency of surveillance through colonoscopy and CT scans. The study found a significantly higher rate of surgery in the older group during the index episode (17% vs. 4.2%, p = 0.000). A higher proportion of patients in the older group were misclassified as Hinchey II (18.2% vs. 6.4%, p = 0.007) and Hinchey III (2.3% vs. 0.7%, p = 0.304). All patients classified as Hinchey III (1 in the younger group and 3 in the older group) underwent emergency surgery. In the younger group, 2 out of 8 emergency surgeries were for patients classified as Hinchey II, compared to 11 out of 28 in the older group. Only 58% of patients underwent any form of imaging or endoscopic surveillance during the first year of follow-up. Among those, complications such as abscess, fistula, or stenosis were observed in 17% of patients, occurring more frequently in the older group (16.9% vs. 5.7%, p = 0.089). Nearly 50% of these patients required surgery, with 6 cases in the younger group and 9 in the older group. Emergency surgeries were more common in the older group (2.4% vs. 0.6%, p = 0.186), as was elective surgery (10.3% vs. 7.9%, p = 0.283). A conservative approach, combined with meticulous monitoring through regular follow-ups and imaging, can be effectively employed in managing patients with acute diverticulitis and pericolic free gas. However, our findings highlight the critical need for rigorous surveillance, especially in older patients, due to the higher prevalence of long-term complications.

Changes in female cancer diagnostic billing rates over the COVID-19 period in the Ontario Health Insurance Plan

Background

The initial response to coronavirus disease 2019 (COVID-19) in Ontario included suspension of cancer screening programs and deferral of diagnostic procedures and many treatments. Although the short-term impact of these measures on female cancers is well documented, few studies have assessed the mid- to long-term impacts.

Objectives

To compare annual billing prevalence and incidence rates of female cancers during the COVID-19 period (2020-2022) to pre-COVID-19 levels (2015-2019).

Design

Retrospective analysis of aggregated claims data for female cancer diagnostic codes from the Ontario Health Insurance Plan (OHIP).

Methods

Linear regression analysis was used to fit pre-COVID-19 (2015-2019) data for each OHIP billing code and extrapolate counterfactual values for the years of 2020-2022. Excess billing rates were calculated as the difference between projected and actual rates for each year.

Results

In 2020, OHIP billing prevalence rates for cervical, breast, uterine, and ovarian cancers decreased relative to projected values for that year by -50.7/100k, -13.9/100k, -3.5/100k, and -3.8/100k, respectively. The reverse was observed in 2021 with rate increases of 47.8/100k, 59.1/100k, 2.5/100k, and 3.7/100k, respectively. In 2022, the excesses were further amplified, especially for cervical and breast cancers (111.2/100k and 78.67/100k, respectively). The net excess patient billing rate for 2020-2022 was largely positive for all female cancer types (108.3/100k, 123.7/100k, 5.2/100k, and 1.8/100k, respectively). Analysis of billing incidence rates showed similar trends.

Conclusion

The expected female cancer billing rate decreases in 2020 were followed by large increases in 2021 and 2022, resulting in a cumulative excess during the COVID-19 period. Further research is required to assess the nature of these changes.

Vacuum-assisted closure or primary closure with relaparotomy on-demand in patients with secondary peritonitis: a systematic review and meta-analysis

BACKGROUND

Secondary peritonitis is a serious condition with significant morbidity and mortality. Its management requires emergency laparotomy for source control. Vacuum-assisted closure (VAC) and primary abdominal closure (PAC) are the main strategies for managing the laparostomy after source control. Despite the increasing use of VAC, concerns persist regarding its complications and long-term outcomes compared with PAC.

METHODS

This systematic review followed PRISMA 2020 and MOOSE. The Cochrane Risk of Bias (RoB 2) tool, MINORS and GRADE framework assessed study quality and evidence certainty. The protocol was registered in PROSPERO (CRD42022304724). A comprehensive search of MEDLINE, Embase, and the Cochrane Library from January 2004 to August 2024 identified studies reporting postoperative outcomes following VAC or PAC after laparotomy for secondary peritonitis. The included studies had to report at least two key outcomes: mortality, postoperative complications, incisional hernia, secondary fascial closure, and hospital or intensive care unit (ICU) length of stay.

RESULTS

Thirty-three studies including 4,520 patients were analyzed. Mortality was 31.1% in VAC and 22.2% in PAC (p = 0.327). Postoperative complications were higher with VAC (71.0% vs. 39.3%, p = 0.001). Incisional hernia rates were similar (21.3% vs. 20.8%, p = 0.958). Secondary fascial closure rate was significantly lower with VAC (58.1% vs. 85.9%, p < 0.001). VAC patients had longer ICU stays (21.1 vs. 9.7 days, p = 0.04), while hospital stay did not differ. Most studies had a high risk of bias, and GRADE assessment showed low to very low evidence certainty.

CONCLUSION

VAC therapy was associated with more postoperative complications, a lower fascial closure rate, and a longer ICU length of stay compared with PAC. Thirty-day mortality rates did not differ between the approaches. However, most of studies included were subject to serious risk of bias and a low level of certainty in evidence.

Impact of Coronavirus Disease (COVID)-19 on the Indigenous Population of Brazil: A Systematic Review

BACKGROUND

Indigenous peoples in Brazil were severely impacted by coronavirus disease (COVID)-19 pandemic, experiencing high rates of infection and mortality. Geographic isolation, limited access to healthcare, socio-economic disparities, and cultural factors, such as communal living and mistrust of state-led initiatives, heightened their vulnerability. Territorial invasions and oxygen shortages further exacerbated the crisis. Therefore, this systematic review aimed to explore the progression of COVID-19 in this population.

METHODS

A systematic review was conducted in PubMed-MEDLINE, SciELO (Scientific Electronic Library Online), and LILACS (Latin America and the Caribbean Health Sciences Literature) from the beginning of the pandemic in Brazil (2020) to March 2025. Studies addressing COVID-19 vaccination and epidemiological, social, and economic aspects among Indigenous populations in Brazil were included. Reviews and irrelevant studies were excluded. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 50 relevant studies were included, grouped into thematic blocks: mortality/infection, symptoms, vaccination/testing, social impacts, and birth outcomes. Several studies highlighted that being male, of Indigenous or other racial minority background, and having comorbidities increased mortality risk. In contrast, asthma was associated with reduced mortality. Pregnant Indigenous women in rural areas had 33 times higher odds of dying than their urban counterparts. Furthermore, there is a higher likelihood of very low birth weight and inadequate prenatal care among Indigenous mothers. Vaccination reduced the risk of death, particularly after full immunization, though it did not prevent hospitalization. A cohort study of 389,753 Indigenous people showed a lower full vaccination rate (48.7%) compared to the general population (74.8%). Complete vaccination reduced the risk of death by 96% among hospitalized patients. Regarding seroprevalence, Indigenous people had a 5.4% positivity rate, much higher than other racial groups, and were 4.71 times more likely to test positive than White, Black, or Mixed Individuals. Socioeconomic disparities also correlated with increased infection risk.

CONCLUSIONS

The COVID-19 pandemic worsened health disparities among Indigenous peoples in Brazil, revealing systemic inequalities, weak public policies, and limited healthcare access. This review urges culturally sensitive, community-led responses and highlights the need for disaggregated data and equitable, inclusive health strategies.

Perioperative SARS-CoV-2 infection and postoperative complications: a single-centre retrospective cohort study in China

OBJECTIVE

To explore the association between perioperative SARS-CoV-2 infection and the postoperative complications during the breakout of the Omicron epidemic wave.

DESIGN

Observational retrospective cohort study. Multivariable logistic regression was performed to explore the association between the duration from surgery to COVID-19 diagnosis and the likelihood of postoperative complications.

SETTING

A general hospital in China.

PARTICIPANTS

7927 patients aged 18 years and older who underwent surgical treatment between 1 December 2022 and 28 February 2023.

PRIMARY OUTCOME MEASURES

The outcome was a composite of postoperative adverse events that occurred within the initial 30 postoperative days.

RESULTS

Of all patients, 420 (11.76%) experienced postoperative complications. Compared with No COVID-19, preoperative COVID-19 within 1 week (pre-1w) exhibited a high risk of postoperative complications (adjusted OR (aOR), 2.67; 95% CI 1.50 to 4.78), followed by patients with pre-2w (aOR, 2.14; 95% CI 1.20 to 3.80). For patients with postoperative COVID-19 within 1 week (post-1w), the aOR was 2.48 (95% CI 1.48 to 4.13), followed by patients with post-2w (aOR 1.95; 95% CI 1.10 to 3.45), and those with post-3w (aOR 2.25; 95% CI 1.27 to 3.98). The risks of postoperative complications decreased roughly with the increase of the time interval between the surgery date and SARS-CoV-2 infection. Stratification analyses suggested that perioperative COVID-19 increased the risk of postoperative complications in older patients, smokers, those with comorbidities or experiencing moderate or severe COVID-19 symptoms.

CONCLUSIONS

Our findings reveal a significant time-dependent relationship between perioperative COVID-19 and postoperative complications, highlighting the importance of tailored preoperative risk evaluations, enhanced postoperative surveillance, and the implementation of effective postoperative COVID-19 prevention measures.

TRIAL REGISTRATION NUMBER

ChiCTR2300072473.

Prospective analysis of adiposity metrics for complicated acute colonic diverticulitis: Should WSES Classification and visceral adiposity be integrated for predictive analyses?

BACKGROUND

Colonic diverticulitis is correlated with age, body mass index (BMI), and increased visceral or subcutaneous fat. Obesity contributes to diverticulosis, diverticulitis and its complications onset, as visceral fat activates inflammatory pathways that exacerbate these conditions. The aim of this study was to evaluate the association of visceral adiposity and BMI on complications of acute colonic diverticulitis.

METHOD

A prospective cohort study was conducted on patients with acute diverticulitis admitted to the general surgery ward of a university hospital in Istanbul from September 2017 to February 2022. A total of 208 patients were classified into uncomplicated and complicated diverticulitis per the World Society of Emergency Surgery guidelines. After documenting demographic, clinical, and laboratory data, along with BMI and computed tomography measurements of visceral and subcutaneous fat areas (VFA, SFA), we conducted a statistical analysis to assess the relationships between VFA, SFA, and BMI in both groups.

RESULTS

Complicated diverticulitis group was found to have significantly lower values of BMI and VFA (p = 0.037 and p = 0.046 respectively). Similarly, BMI and VFA values of patients who underwent all interventional procedures including percutaneous drainage and surgery were found to be significantly lower than the conservative treatment group (p = 0.007, p = 0.025 respectively). V/S < 0.68 is an independent predictor in the complicated group.

CONCLUSION

Our study shows that complicated diverticulitis cases have lower BMI and visceral fat area. We suggest that increased visceral adipose tissue may serve a protective role by preventing these diverticula from developing into more complicated forms. Therefore, visceral adiposity metrics can be integrated in the predictive analyses.

Effectiveness of Systemic Inflammation Response Index (SIRI) Neutrophil-Lymphocyte Ratio (NLR), Derived Neutrophil-Lymphocyte Ratio (dNLR), and Systemic Immune Inflammation Index (SII) for predicting prognosis of acute diverticulitis

There are many applications to emergency services due to acute colonic diverticulitis. It is necessary to decide whether these patients are complicated, to quickly predict their prognosis, and to decide whether medical or invasive treatment is necessary. We planned to research effectiveness NLR, NLR, SII, and SIRI values calculated using hemogram data can predict the prognosis of acute diverticulitis. We managed a retrospective scanning with patients who applied with a diagnosis of acute diverticulitis between 06/2020 and 04/2023. Demographic data (age, gender, previous surgery, comorbid diseases), tomographic Hinchey classification, location of diverticulitis, applied treatment, and obtained from blood parameters at presentation to the emergency department WBC, CRP, NLR, dNLR, SII, SIRI parameters were recorded from the electronically registered patient files. According to the Hinchey classification, those with Hinchey 0 and 1a were included in the noncomplicated group A class because they were followed up with outpatient medical follow-up. Those with Hinchey 1b,2,3,4 were included in the complicated GROUP B class. Differences in WBC, CRP, NLR, dNLR, SIRI, SII values between the complicated and noncomplicated groups were evaluated statistically. There were 286 patients with acute diverticulitis on the dates indicated. The number of patients eligible for the study was eighty-two. According to Hinchey's classification, 56 patients had noncomplicated acute diverticulitis (SAD) and 26 patients had complicated diverticulitis (CAD). These diagnoses were given based on tomography findings and clinical evaluations. The hospital stay was longer in the CAD group compared to the SAD group (p < 0.001) statistically significantly. The rate of surgical procedures and percutaneous interventions in the CADs was higher than SADs (p: 0.040) statistically significantly. WBC (white blood cell), NLR, dNLR, SIRI, SII and CRP parameters were higher in CADs than in SADs as statistically significant. Spearman's correlation analysis showed between the Hinchey classification and the NLR, dNLR, SII, SIRI, CRP, WBC parameters with high correlation as positive. Determination of values SIRI (2.42), NLR (3.35), SII (907.44) dNLR (4.63), CRP (15.25) WBC (11.16) and specificity and fractionation of these values ROC analysis was performed for this purpose. Highest AUC (area under the curve) value was found in WBC [0.807 0.703-0.910)], SIRI [0.786 (, 0.681-0.892)], SII [0.767 (0.654-0.880)], NLR [0.740 (0.624-0.854)], dNLR [0.739 (0.625-0.853)]. This study showed that there are SII, SIRI dNLR, NLR, CRP, and WBC values in patients presenting with acute diverticulitis a very high correlation with Hinchey classification in distinguishing complicated and non-complicated acute diverticulitis (p < 0.01). These data were higher in CADs than in SADs statistically significantly. The use of these data can both prevent unnecessary radiation in patients suspected of acute diverticulitis by reducing unnecessary tomography scans and can be valuable in predicting the prognosis of diverticulitis at a low cost.

Endoscopic direct diverticulitis therapy for acute uncomplicated diverticulitis

The global prevalence of acute uncomplicated diverticulitis is increasing, and patient care for this condition is experiencing a paradigm shift. This study evaluated the diagnostic and therapeutic value of endoscopic direct diverticulitis therapy (EDDT) using cholangioscope-assisted colonoscopy for acute uncomplicated diverticulitis.Patients with computed tomography-confirmed acute uncomplicated diverticulitis (Hinchey stage Ia or Ib) who underwent EDDT between July 2023 and December 2024 were included. The technical success rate of EDDT, procedure time, endoscopic findings, symptom resolution, and recurrence were documented.12 patients (mean age 45.2 [SD 10.1] years, 10 males) underwent EDDT. Technical success was achieved in all 12 patients (100%). Cholangioscope-assisted colonoscopy revealed fecaliths with pus in seven patients, copious purulent collection in four, edematous inflammatory mucosa in five, and bleeding in one. Corresponding treatments were applied without complications. Abdominal pain resolved immediately after EDDT, and inflammatory parameters returned to normal. No recurrences were reported over a mean follow-up of 4 months (range 1-10 months).EDDT utilizing cholangioscope-assisted colonoscopy was a feasible alternative treatment for acute uncomplicated diverticulitis, offering diagnostic and therapeutic advantages through direct visualization. Although preliminary results are promising, further studies with larger cohorts are warranted to confirm its efficacy and long-term outcomes.

Antimicrobial Stewardship Impact on the Treatment of Intra-abdominal Infections in the Surgical Intensive Care Unit

Background: Broad-spectrum antibiotic agents are utilized for complicated intra-abdominal infection (cIAI); however, the need for empiric methicillin-resistant Staphylococcus aureus (MRSA) coverage is not clear as the incidence of MRSA cIAI is rare. Patients and Methods: A single-center, retrospective, pre- and post-cohort study of adults admitted to the surgical intensive care unit (SICU) with cIAI between March 1, 2021, to May 1, 2023, was conducted. Historically, the SICU utilized vancomycin for all cIAI; however, in April 2022, the preferred regimen was changed to either piperacillin-tazobactam with vancomycin added for patients with MRSA risk factors or for Enterococcus spp. coverage in cefepime- or levofloxacin-based regimens for penicillin-allergic patients. The primary outcome was number of vancomycin days of therapy (DOT) per 1,000 patient days. Categoric and continuous variables were analyzed with chi-square and Fisher exact tests. Results: A total of 142 SICU encounters were included, 64 in the pre-cohort and 78 in the post-cohort. There was no difference in median vancomycin DOT per 1,000 patient days (14 days [interquartile range or IQR 5-21]; 16 days [IQR 8-17] p = 0.522) between the pre- and post-cohort. There was a significant reduction in the number of patients given vancomycin after the protocol change (90.6%; 76.9%, p = 0.042). A significant increase in piperacillin-tazobactam exposure was also observed (48.4%; 82.1%, p < 0.001) in the post-cohort aligning with our institutional practice change. Conclusions: In critically ill surgical patients with cIAI, the implementation of an antimicrobial stewardship guideline did not reduce vancomycin DOT per 1,000 patient days, however, it did result in a significant reduction in vancomycin exposure.

Untargeted metabolomics for acute intra-abdominal infection diagnosis in serum and urine using UHPLC-TripleTOF MS

Introduction

Acute intra-abdominal infection (IAI) is a prevalent and life-threatening condition in general surgery, with significant implications for patient mortality. However, the timely identification of IAI is often hindered by the limitations of current medical laboratory sciences and imaging diagnostics.

Methods

To address this critical issue, we employed metabolomics to identify early biomarkers for IAI. In this study, we enrolled a cohort of 30 IAI patients and 20 healthy volunteers. Following preliminary experimental processing, all serum and urinary samples were subjected to ultrahigh performance liquid chromatography-triple time-of-flight mass spectrometry analysis. Initial metabolite profiling was conducted using total ion current chromatography and principal component analysis. Differential metabolites were subsequently identified through Student's t-test, partial least squares discriminant analysis, and support vector machine. Hierarchical clustering analysis was then applied to assess the discriminatory power of the selected metabolites. Based on receiver operating characteristic curve analysis, we identified the most promising biomarkers, which were further subjected to enrichment analysis. Additionally, we stratified patients according to the severity and etiology of IAI to explore potential differences among these subgroups.

Results

Our findings revealed five serum and two urinary metabolites as potential biomarkers for IAI. The serum biomarkers were associated with the Fatty Acid Biosynthesis pathway, while the urinary biomarkers were linked to the Catecholamine Biosynthesis pathway. Notably, no significant differences were observed among the three types of IAI or the seven etiologies studied.

Discussion

For individuals at risk of IAI, regular screening of these biomarkers could facilitate the early and convenient identification of the condition, thereby improving patient outcomes.

Abnormal blood glucose on admission and outcomes in older patients with acute calculous cholecystitis

INTRODUCTION

We investigated the potential correlation between abnormal blood glucose on admission and clinical outcomes of acute calculus cholecystitis in older patients.

AREAS COVERED

We included older patients (≥65 years) diagnosed with acute calculus cholecystitis. The first plasma glucose measurement obtained at admission was used. Overall, 280 older patients were evaluated. The results showed that ABG was significantly associated with more severe systemic inflammatory responses (elevated white blood cell count and neutrophil-lymphocyte ratio), a higher incidence of moderate to severe ACC, and the need for invasive treatment (an increased proportion of percutaneous cholecystostomy and combined surgeries). The prolonged hospital stay, 30-day readmission rate and mortality rate of patients in the ABG group were significantly increased, and the incidence of severe postoperative complications (Clavien-Dindo≥grade III) was higher. Multivariate analysis confirmed that ABG was an independent predictor of the severity of ACC (TG18 classification) and 30-day re-admission rate.

EXPERT OPINION/COMMENTARY

In older patients with acute calculus cholecystitis, abnormal blood glucose on admission is associated with worse outcomes, serving as a novel quantifiable risk criterion to guide treatment selection, particularly for high-risk older adults ineligible for early surgery.

Necrotising enterocolitis in adults: a rare occurrence

Necrotising enterocolitis (NEC) is a life-threatening condition predominantly affecting preterm neonates. In contrast to well-characterised neonatal forms, adult NEC (ANEC) is a rare entity. Early diagnosis is crucial, as NEC carries a high mortality rate if left untreated. This report describes a man in his 80s presenting with acute abdomen subsequently diagnosed as ANEC. This case emphasises diagnostic challenges and highlights the key differences between the neonatal and adult forms of the disease. This case contributes to the limited literature on ANEC, supporting the need for early diagnosis and management of this rare condition in adults.

Biceps breakdown: a case of spontaneous necrotizing myositis

We report a case of spontaneous necrotizing myositis of the biceps brachii in an immunocompetent patient with no comorbidities. We highlight the diagnostic challenges with this case, the utility of computed tomography in diagnosing soft tissue infections, and the importance of source control in septic patients.

Assessment of anaesthesia trainees using performance metrics derived from electronic health records: a longitudinal cohort analysis

BACKGROUND

The development of competencies in anaesthesia residents is assessed by direct observation of their performance and written and oral examinations. Little is known about how residents' competencies are reflected by objective data in anaesthetic records. We investigated whether performance metrics derived from electronic anaesthesia records are associated with anaesthesia residents' progress of training and European written examination timing and results.

METHODS

We recruited 46 anaesthesia providers who trained at the Vienna University Hospital between September 2013 and June 2021, and we reviewed the anaesthesia records of all cases they managed during the study period. We derived six performance measures based on perioperative data routinely collected: intraoperative hypotension and hypothermia, glycaemic control, postoperative nausea and vomiting prevention, lung-protective ventilation, and postoperative kidney injury. We evaluated the association between these quality metrics with training level and written exam completion status in anaesthesia residents after adjusting for patient and surgical factors.

RESULTS

We found a statistically significant association between the level of training and most performance measures. The probability of preventing intraoperative hypotension increased (OR 1.16, 95% CI 1.12 - 1.20) with the level of training, as did the probability of preventing hypothermia (OR 1.08, 95% CI 1.05 - 1.11) and administering appropriate postoperative nausea and vomiting prophylaxis (OR 1.21, 95% CI 1.15 - 1.27). However, the odds of preventing acute kidney injury decreased (OR 0.91, 95% CI 0.83 - 0.99), as did the use of lung-protective ventilation (OR 0.94, 95% 0.92 - 0.97). All participating residents who took the written exam passed it, precluding a direct pass versus fail comparison, but the exam completion status was associated with increased odds of lung-protective ventilation (OR 1.42, 95% CI 1.03 - 1.95) and decreased odds of preventing intraoperative hypotension (OR 0.7, 95% CI 0.49 - 0.99). Glycaemic control was not associated with either of the training milestones.

CONCLUSIONS

The training level of anaesthesia residents had a significant association with several performance metrics. Passing the written exam only had a modest effect. Performance measures based on patient outcomes and intraoperative care may serve as assessment methods for anaesthesia residents' progress tracking.

Post-Surgical Abdominal Myonecrosis: The Unusual Role of Candida albicans

Necrotizing myonecrosis is a life-threatening infection of the skeletal muscle and soft tissues, predominantly caused by bacteria such as Staphylococcus aureus and Group A Streptococcus. In rare cases, fungal organisms, particularly Candida albicans, have been identified as the sole causative agent in these infections. We present a rare case of a 77-year-old female patient who underwent an elective hysterectomy that was complicated by an iatrogenic injury to her small bowel, which was missed in the preliminary surgery. Postoperatively, she developed signs of peritonitis and greenish-brown drainage from her incision site. Exploratory laparotomy confirmed small bowel perforation. Subsequently, she developed abdominal sepsis and necrotizing myonecrosis involving the anterior abdominal wall musculature. Empiric treatment with broad-spectrum antibiotics was initiated. Intraoperative cultures revealed isolated Candida albicans, prompting a shift in management to antifungal therapy and multiple surgical debridements of the anterior musculature.

Multicentre Study of 10,369 Symptomatic Patients Comparing the Diagnostic Accuracy of Colon Capsule Endoscopy, Colonoscopy and CT Colonography

BACKGROUND

During the COVID-19 pandemic, NHS England introduced colon capsule endoscopy (CCE) at scale to support the recovery of endoscopy. Symptomatic patients referred with suspected colorectal cancer (CRC) and a faecal immunochemical test (FIT) ≤ 100 μg Hb/g faeces were offered CCE.

AIMS

To evaluate the safety, diagnostic accuracy and utility of CCE in this setting.

METHODS

Consenting patients, referred on a suspected CRC pathway with FIT ≤ 100 μg Hb/g faeces, were offered CCE, colonoscopy or CT colonography. Each cohort was to be age-, sex-, symptom- and FIT-matched. We performed a paired comparison of findings in those who required colorectal endoscopy after CCE and recorded clinical outcomes.

RESULTS

We recruited 4878 patients for CCE, 5025 for colonoscopy and 466 for CT colonography patients. CCE was safely tolerated by 98.4% of patients. CCE identified a matched mass lesion in all patients with CRC when the examination was complete and adequately prepared. More polyps ≥ 10 mm and 6-9 mm were detected by CCE than by colonoscopy or CT colonography. Per-patient sensitivities for polyps ≥ 10 mm and 6-9 mm were 97% in those with a paired, complete and adequately prepared CCE than colonoscopy. Completion (74%) and bowel preparation adequacy rates (74%) were poorer than those of colonoscopy and CTC (both 88%). However, CCE usefully performed a filter function in 86% of patients.

CONCLUSIONS

CCE is safe and accurate for the diagnosis of colorectal disease. In the suspected CRC pathway, its 'filter function' complements existing colorectal diagnostic services by creating additional capacity.

Preoperative iron supplementation in non-anemic patients undergoing major surgery: a systematic review and meta-analysis

BACKGROUND

Blood transfusions are associated with increased morbidity and mortality, and maintaining global blood supplies can be a challenge. This systematic review investigates the impact of preoperative iron supplementation on the risk of blood transfusion among non-anemic patients undergoing major surgeries.

METHODS

We conducted a systematic search of PubMed, Embase, and Cochrane Central for randomized controlled trials published up to May 2024. Studies involving the use of erythropoietin, or patients already using iron supplementation when trial randomization was conducted were excluded. Outcomes assessed included the number of individuals who received blood transfusions, and mean hemoglobin levels at the first day and by the first postoperative week.

RESULTS

A total of 1,162 non-anemic patients from 9 studies were included. Of these, 54% received preoperative iron supplementation. The average age was 71 years, and 44% were women. Preoperative iron supplementation was associated with a significantly lower risk of receiving a blood transfusion (OR = 0.54; 95% CI 0.40 to 0.75; p < 0.001). At the first postoperative day, the iron supplementation group had significantly higher mean hemoglobin levels compared to the no-treatment group (MD = 0.22 g.dL-1; 95% CI 0.02 to 0.42; p = 0.03). However, the pooled results could not rule out the null hypothesis for the difference in mean hemoglobin levels throughout the first week (MD = 0.12 g.dL-1; 95% CI -0.12 to 0.35; p = 0.34).

CONCLUSION

Preoperative intravenous iron supplementation in non-anemic patients undergoing major surgeries, particularly cardiac procedures, significantly reduces transfusion requirements. However, the benefits of oral iron remain uncertain, and further research is warranted to establish standardized perioperative supplementation protocols.

PROSPERO IDENTIFIER

CRD42024552559.

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.

Real-time ancillary diagnostics for intraoperative assessment of intestinal viability in horses-looking for answers across species

Clinical intestinal viability assessment is associated with significant limitations, and there is an undisputable need for ancillary diagnostics during colic surgery. Human and companion animal surgeons struggle with similar intraoperative issues, yet there is little exchange between specialists. Therefore, this narrative review aimed to create an overview of real-time ancillary diagnostics with the potential for intraoperative intestinal viability assessment in horses. Most real-time ancillary diagnostics can be classified as either tissue perfusion or oxygenation assessments. Intestinal perfusion may be quantified using dark field microscopy, laser Doppler flowmetry, or fluorescence angiography (FA). In particular, indocyanine green FA has gained popularity in human medicine and is increasingly employed to predict intestinal injury. Intestinal oxygen saturation can be measured by pulse oximetry or mixed tissue oximetry. The latter can be conducted using visible light or near-infrared spectrophotometry, and these measurements correlate with clinical outcomes in various species. Other real-time diagnostics include thermography and techniques currently under development, such as laser speckle flowgraphy or photoacoustic imaging. The modalities discussed are minimally invasive and may be used for intraoperative assessments of the intestine. However, limitations include the occurrence of artifacts and the subjective nature of some modalities. Techniques such as indocyanine green FA and tissue oximetry are already available in veterinary practice and have the potential for use during colic surgery. However, blinded clinical trials are lacking in all species, and more research is needed to determine the accuracy and cutoff values in equine-specific intestinal lesions.

In vitro activity of ceftolozane/tazobactam against ESBL-producing enterobacterales in China: SMART 2016-2019

OBJECTIVES

To evaluate the in vitro susceptibility of ESBL-producing Enterobacterales isolates to ceftolozane/tazobactam (C/T), a combination of tazobactam (a ß-lactamase inhibitor) and a new antipseudomonal cephalosporin.

METHODS

From 2016 to 2019, susceptibilities of 10,545 Enterobacterales isolated from intra-abdominal, urinary tract, respiratory tract and bloodstream infections to C/T and 11 other antimicrobial agents were analyzed. Non-ESBL-producing isolates were included for comparative analysis to provide a comprehensive susceptibility profile.

RESULTS

Among 10,545 isolated Enterobacterales, 54.6% were ESBL producers. The ESBL-positive rates for E. coli (4984/10,545, 47.3%) and K. pneumoniae (3606/10,545, 34.2%) were 59.8% and 51.1%, respectively. The susceptibility rate to C/T for all Enterobacterales was 79.5%. For E. coli and K. pneumoniae, the C/T susceptibilities were 89.3% and 68.0%, respectively. For non-ESBL-producing Enterobacterales, susceptibility to C/T was 99.5%. The susceptibility of non-carbapenem-resistant (CR) ESBL-producing Enterobacterales to C/T was 81.0%. The isolation rates of ESBL-positive and carbapenem-resistant Enterobacterales (CRE), CR-E. coli, and CR-K. pneumoniae were 14.3%, 5.6% and 26.8%, respectively. The susceptibility of ESBL-positive CREs to C/T was <20% for most antimicrobials except amikacin (50.4%). The susceptibility of ESBL-positive CR-E. coli to C/T was 28.2. For ESBL-producing CR-K. pneumoniae, susceptibility to most antimicrobials was <10%, except for amikacin (37.4%).

CONCLUSIONS

The present research underscores the viability of C/T as an alternative to carbapenems for the treatment of ESBL-producing, carbapenem susceptible Enterobacterales. However, the susceptibilities of ESBL-positive CRE to C/T and other studied antimicrobials were consistently below 20%, emphasizing for new innovative treatment strategies.

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.

Therapeutic efficacy of Xuebijing injection in treating severe acute pancreatitis and its mechanisms of action: A comprehensive survey

BACKGROUND

Severe acute pancreatitis (SAP) is a life-threatening condition associated with high mortality and limited therapeutic options. Current management strategies focus on infection prevention, immune regulation, and anticoagulation. Xuebijing Injection (XBJ), a widely used traditional Chinese medicine-derived intravenous preparation, has shown promising therapeutic effects in SAP. Herein, we sought to evaluate clinical and preclinical evidence on XBJ to reveal its potential mechanisms of action, and provide insights to guide future research and clinical applications.

METHODS

We conducted a comprehensive survey of studies on XBJ in the treatment of SAP across PubMed, Embase, Cochrane Library, CBM, CNKI, Wanfang and VIP databases from their inception to March 21st, 2024.

RESULTS

A total of 239 studies were included, comprising 12 animal experiments, 7 systematic reviews, 220 clinical trials. Mechanistic studies suggest that XBJ downregulates the expression of inflammatory mediators, improves immune function, and alleviates oxidative stress via multiple signaling pathways, including the TLR4/NF-κB, p38-MAPK, HMGB1/TLR, TLR4/NF-κB, FPR1/NLRP3, and JAK/STAT pathways. These effects contribute to reducing organ damage. Compared to standard treatment, XBJ has more effective at reducing mortality and complications, improving overall clinical outcomes, shortening ventilator use time, and hospital stay in SAP patients.

CONCLUSIONS

Preclinical evidence and clinical trial data indicated that XBJ can simultaneously regulate inflammatory responses, immune function, microcirculatory disorders, oxidative stress, and apoptosis. However, further research is required to elucidate the specific mechanisms of action, clinical characteristics and safety of XBJ.

Is there consensus on diagnostics and treatment in colonic diverticulitis? Results of international survey

BACKGROUND

Clinical guidelines (CGs) developed by expert communities benefit both the patient and the clinician. Meanwhile a considerable proportion of specialists are not familiar with or follow them in their daily practice. Colonic diverticulitis (CD) is the third most common cause of hospitalization among patients with gastrointestinal diseases and common indication for colon resection. Actual tactics for diagnosis and treatment of CD, as well as data on what influences its choice and how the decisions made agree with the existing CGs can be identified by anonymous surveys.

METHODS

An anonymous internet survey of surgeons and coloproctologists was conducted. Groups of questions included demographics of the respondents; self-esteem score; sources of guidance in decision-making; classification systems for CD; preferable diagnostic tests; management of CD; indications for elective surgery; and outcomes of surgical treatment and others (n = 17). The study was conducted in accordance with the CHERRIES criteria. The required minimum sample size was calculated as 377 participants.

RESULTS

The study involved 401 respondents from 9 countries: 76.1% were general surgeons and 14.5% were colorectal surgeons. Excellent or good knowledge of the problem was claimed by 82.8% of the colorectal vs 66.2% of the general surgeons (p = 0.013). In decision-making respondents were largely guided by their professional experience, methods adopted in their clinic and domestic CGs. General Surgeons more often chose tactics inconsistent with CGs than coloproctologists. The largest differences between subgroups were noted for awareness of the reversal of Hartmann's procedure, most common postoperative complications and indications for elective surgery.

CONCLUSION

Adherence to the existing CGs was poor, which entails significant variation in the approaches practiced by the respondents from different cohorts. There is no consensus on the aspects that are not yet covered in the CGs. Further research is needed to elucidate these gaps and update the guidelines accordingly.

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.

Analysis of the outcomes of postdiverticulitis investigations: a multicentre cohort study including 1,120 patients

INTRODUCTION

The aim of this study was to assess the yield of the endoscopic investigations performed following the resolution of acute diverticulitis.

METHODS

A retrospective multicentre study included patients with multislice computed tomography (MSCT)-proven diverticulitis, in four NHS hospitals, between January 2016 and April 2023. The primary outcome was the rate of colonic cancer in the diseased segment. Secondary outcomes included the rate of malignancy in the nondiseased colonic segments, the benign colonic polyp detection rate, the rate of malignancy in the resected surgical specimens in patients who underwent an emergency surgery on the index admission and the rate of complications in the investigated group.

RESULTS

A total of 1,120 patients were included in the study, out of which 604 were females, with a median age of 61 years; 731 patients (65%) had uncomplicated diverticulitis (Hinchey 1A) while 389 (35%) had complicated diverticulitis (Hinchey 1B-4). Following the acute episode, 757 (74%) patients had subsequent endoscopic evaluation. The incidence of colorectal cancer (CRC) or advanced adenomas (AA) in patients with uncomplicated diverticulitis was 0.14%. In the complicated diverticulitis group, the incidence of CRC/AA in patients with Hinchey 1b and Hinchey 2 was 1.4% and 5.4%, respectively. Out of the 107 patients who underwent emergency colonic resection for suspected perforated diverticulitis, 18 (16.8%) had histological evidence of colonic malignancy.

CONCLUSIONS

Endoscopic investigations following uncomplicated diverticulitis have a low yield for sinister colonic pathology. Colonoscopy should be planned following complicated diverticulitis and in patients with uncomplicated diverticulitis with suspicious radiological finding on index imaging or in patients with ongoing clinical manifestations. In patients who undergo emergency surgery, oncological principles should be applied whenever possible.

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.

Diverticulitis in Older Adults: A Review of Etiology, Diagnosis, and Management

BACKGROUND

Diverticulitis accounts for over 300,000 hospitalizations annually in the United States and its incidence increases with age. Among older adults, diverticulitis is the fourth leading cause for emergency surgery. Older adults with multimorbidity and geriatric syndromes are often excluded from clinical studies, leaving a gap in the evidence needed to guide management. Here, we provide a clinically oriented review of the diagnosis and management of older adults with diverticulitis through the lens of age-friendly care.

METHODS AND RESULTS

We reviewed the literature describing the epidemiology, diagnosis, management, and prevention of diverticulitis in older adults. Due to age-related physiologic changes, the presence of geriatric syndromes, and multimorbidity, older adults with diverticulitis often present with atypical symptoms, variable laboratory findings, and are at higher risk for complications than younger patients. Guidelines support a more aggressive approach to diagnosis in this population, with lower threshold for obtaining diagnostic imaging. Antibiotics remain a mainstay of treatment for uncomplicated disease, and surgical management should be focused on severity of disease and the balance between the likelihood of improving quality of life and risks and burden of treatment.

CONCLUSIONS

Diverticulitis is a common disease that has a unique presentation among older individuals with limited evidence to guide management. Diagnosis and treatment should focus on what matters most to the patient, providing the most meaningful outcome possible within the context of multimorbidity, patient goals, symptom burden, and anticipated treatment outcomes.

Meta-analysis and systematic review of long-term quality of life and recurrence following elective surgery versus non-operative management for colonic diverticulitis

BACKGROUND

Limited data exist on long-term outcomes of elective surgery versus nonoperative management of complicated diverticulitis. We aimed to assess long-term outcomes of nonoperative management versus elective surgery in patients initially conservatively treated for diverticulitis.

METHODS

Systematic review of PubMed and Scopus for studies comparing elective resection and nonoperative management of acute diverticulitis from inception to December 2023 was conducted. Studies reporting long-term outcomes (≥2 years) were included. Main outcomes were quality of life, disease recurrence, and long-term ostomy.

RESULTS

After screening 1,488 studies, 3 randomized controlled trials and 6 retrospective studies (3,621 patients; 44.4% males; median age: 59 years) were included. Elective colon resection was associated with significantly higher Gastrointestinal Quality of Life Index scores (mean difference 6.06, 95% confidence interval 2.22-9.9, P = .002), and Short Form Health Survey-36 scores for both mental and physical components (mean differences: 3.47 and 3.42, respectively). Gastrointestinal Quality of Life Index score difference was more noted in the randomized controlled trial subgroup analysis (mean difference: 8.68, 95% confidence interval 3.37-14.0, P = .001). These effect sizes were small according to Cohen d (0.34 and 0.31, respectively). Elective resection was associated with significantly less disease recurrence (odds ratio 0.29, 95% confidence interval 0.13-0.64, P = .002) than nonoperative management. No significant difference in long-term stoma was observed (odds ratio 1.52, 95% confidence interval 0.89-2.6, P = .12).

CONCLUSION

Elective resection was associated with significantly improved long-term quality of life and reduced recurrence of acute diverticulitis. However, the clinical significance of the difference in quality of life scores between the treatment approaches remains uncertain because of the small effect size observed. Any quality of life improvements must be balanced against surgical morbidity and mortality.

Low sarcopenia index predicts intra-abdominal infection in patients with abdominal trauma

OBJECTIVES

Prediction of intra-abdominal infection (IAI) in patients with abdominal trauma is crucial, yet reliable predictive indicators are currently lacking. The sarcopenia index (SI) is a readily available indicator of clinical outcomes in several diseases that holds diagnostic and prognostic value. The aim of this study is to assess the predictive value of SI for IAI in patients with abdominal trauma.

METHODS

This retrospective cohort study enrolled patients with abdominal trauma. Multivariable logistic analyses were used to identify independent factors of IAI. We divided patients into 2 groups based on sex. The receiver operating characteristic (ROC) curve was used to evaluate the performance of SI in predicting IAI. Then, based on the cut-off values of the SI established for males and females, we stratified patients into high and low-IAI risk groups to compare clinical outcomes. Spearman correlation analysis was used for correlation analysis.

RESULTS

A total of 378 participants with abdominal trauma were included. Multivariable logistic analyses identified SI as an independent risk factor for IAI in both males [odds ratio (OR): 0.82, 95% confidence interval (CI): 0.74-0.90, P < 0.001] and females (OR: 0.68, 95% CI: 0.51-0.91, P = 0.009). The area under the ROC curve for SI in predicting IAI was 0.712 for males and 0.733 for females, with optimal cut-off values of 81.430 for males and 57.907 for females. Furthermore, SI showed significant correlations with the length of hospital stay (P = 0.003) and hospital costs (P = 0.042).

CONCLUSIONS

SI was identified as an independent risk factor for IAI in patients with abdominal trauma, offering predictive value for both genders. SI correlates with poor clinical outcomes. This might provide new ideas and theoretical guidance for diagnosing and treating IAI.

Balancing Ethics and Innovation: Can Artificial Intelligence Safely Transform Emergency Surgery? A Narrative Perspective

Background: Artificial intelligence (AI) is increasingly shaping the landscape of emergency surgery by offering real-time decision support, enhancing diagnostic accuracy, and optimizing workflows. However, its implementation raises significant ethical concerns, particularly regarding accountability, transparency, patient autonomy, and bias. Objective: This perspective paper, grounded in a narrative review, explores the ethical dilemmas associated with AI in emergency surgery and proposes future directions for its responsible and equitable integration. Methods: A comprehensive narrative review was conducted using PubMed, Scopus, Web of Science, and Google Scholar, covering the literature published from January 2010 to December 2024. We focused on peer-reviewed articles discussing AI in surgical or emergency care and highlighting ethical, legal, or regulatory issues. A thematic analysis was used to synthesize the main ethical challenges. Results: Key ethical concerns identified include issues of accountability in AI-assisted decision-making, the "black box" effect and bias in algorithmic design, data privacy and protection, and the lack of global regulatory coherence. Thematic domains were developed around autonomy, beneficence, justice, transparency, and informed consent. Conclusions: Responsible AI implementation in emergency surgery requires transparent and explainable models, diverse and representative datasets, robust consent frameworks, and clear guidelines for liability and oversight. Interdisciplinary collaboration is essential to align technological innovation with patient-centered and ethically sound clinical practice.

Necrotizing soft tissue infections: a surgical narrative review

Necrotizing soft tissue infections represent a spectrum of diseases characterized by extensive necrosis involving the skin, subcutaneous tissues, fascia or muscles. These infections are generally severe and rapidly progressive, often accompanied by sepsis, septic chock, multiple organ failure and, ultimately, death. Several classifications have been developed based on multiple parameters, such as the anatomical location of the disease, the depth of the lesion or the microbiology. Numerous clinical factors predispose individuals to the development of necrotizing soft tissue infections. The clinical presentation is not always characterized by local signs and systemic symptoms of infection, which can lead to delays in both diagnosis ad treatment. Broad-spectrum antibiotic directed at the likely organisms is essential early in the treatment course, but do not substitute surgical management. Antibiotic therapy should be subsequently tailored to the etiologic micro-organism. Rapid recognition and early surgical intervention form the mainstay of management of necrotizing soft tissue infections. Initial surgical debridement should be promptly performed preferably at the presenting hospital, when adequate infrastructure and personnel are available. Transfer to a referral center may be necessary for definitive surgical and complex wound care. Most patients require more than one debridement. A multidisciplinary approach is also essential to improve the results in the treatment of these patients.

Temporal trends in cross-country inequalities of early-onset pancreatic cancer: a comprehensive analysis for the global burden of disease study 2021

By 2040, pancreatic cancer is expected to become the second leading cause of cancer-related deaths in the U.S., with early-onset pancreatic cancer (EOPC) cases rising among adolescents and young adults. This study uses the global burden of disease (GBD) 2021 dataset to examine global, regional, and national EOPC trends and predicts the burden through 2050. The analysis covers EOPC burden from 1990 to 2021, focusing on age-standardized prevalence rate (ASPR), incidence rate (ASIR), mortality rate (ASMR), and disability-adjusted life years rate (ASDR). Annual percentage change (APC) and average annual percentage change (AAPC) were calculated via joinpoint regression. Clustering and frontier analysis based on the sociodemographic index (SDI) assessed the link between development levels and health outcomes. We used WHO-recommended health equity methods to quantify EOPC burden disparities and applied a Bayesian age-period-cohort (BAPC) model to project trends. In 2021, EOPC cases rose to 42,254, a 73% increase from 1990, while deaths reached 26,996, up 57%. Although ASIR, ASMR, and ASDR declined, ASPR rose (EAPC = 0.1). Central and Eastern Europe had the highest EOPC burden, with the fastest growth in Australasia (EAPC = 2.78) and Western Sub-Saharan Africa (EAPC = 2.25). Males had about double the burden of females, though female prevalence increased. The widening gap in health burden between low- and high-SDI regions is especially concerning. While EOPC currently affects high-SDI countries the most, there is a clear trend over time showing a gradual shift of EOPC burden towards low-SDI countries. By 2050, ASIR, ASPR, ASMR, and ASDR are projected to stabilize, with cases increasing until 2036, then decreasing. High-SDI countries bear a disproportionately high EOPC burden, with significant diagnostic and management challenges, particularly in Central and Eastern Europe. Rising global EOPC prevalence highlights the need to identify burden differences and risk factors across countries to develop targeted prevention and control strategies.