To compare implant failure rates, reoperations, and postoperative mobilization between lateral locked plate (LLP), retrograde intramedullary nail (rIMN), and nail-plate combination (NPC) constructs in treating distal femur fractures. Retrospective cohort study. Single level 1 trauma center. Adult patients treated operatively for distal femur fractures (OTA/AO 33A and 33C) from 2019 to 2024 were included. Patients were excluded if they sustained partial articular injuries, pathologic fractures, multifocal femoral injuries, or critical bone defects. Construct failure was the primary outcome, defined as displaced implant breakage, gross loss of fracture reduction, or any reoperation for nonunion. Secondary outcomes included all-cause reoperation, deep infection, death within 90 days, and mobilization status at the time of discharge. In total, 196 distal femur fractures in 188 patients were included. There were 83 fractures treated with NPC fixation (mean age 70 years, 24% men, BMI 31), 37 fractures treated with rIMN (mean age 55 years, 54% men, BMI 28), and 76 fractures treated with LLP (mean age 65 years, 29% men, BMI 32). Across the 3 treatment groups, patients with rIMN were younger ( P < 0.001) and had a higher proportion of men ( P = 0.004). Immediate weightbearing was allowed in 70% of NPC constructs, 32% of rIMN constructs, and 3% of LLP constructs, respectively ( P < 0.001). After controlling for age, BMI, and open fracture status, NPC was associated with a lower risk of construct failure, occurring in 1 of 83 (1.2%) cases, compared with LLP, which failed in 15 of 76 (19.7%) cases (hazard ratio 17.43 [95% confidence interval [CI], 2.23-136.10], P = 0.006). Although NPC had the lowest rate of failure among the 3 constructs, the difference between NPC and rIMN, which failed in 2 of 37 (5.4%) cases, was not statistically significant (hazard ratio 7.62 [95% CI, 0.66-88.24], P = 0.104). All-cause reoperation occurred in 7 (8.4%) patients in the NPC group, 4 (10.8%) patients in the rIMN group, and 18 (24.7%) patients in the LLP group. Deep infection occurred in 6 (7.2%) patients in the NPC group, 1 (2.7%) patient in the rIMN group, and 1 (1.3%) patient in the LLP group ( P = 0.085). There were no differences in estimated blood loss ( P = 0.137), or death ( P = 0.999) between groups. Geriatric patients (age ≥60 years) with NPC fixation were more likely to discharge within a higher mobilization strata relative to single implant constructs (OR 2.93, P = 0.049). NPC and rIMN demonstrated a lower hazard of construct failure and reoperation than LLP in the treatment of acute distal femur fractures. Although NPC had a higher number of deep infection cases, controlling for multiple comorbidities found no statistical difference in infection rates between NPC, LLP, and rIMN, but rather an increased risk of infection in smokers and patients with high BMI. NPC fixation was associated with improved postoperative mobilization in geriatric patients compared with single implant constructs. Therapeutic, Level III. See Instructions for Authors for a complete description of levels of evidence.

Eating behaviour traits (EBTs), individuals' reactions to food, food-related cues, and food intake, play an important role in the development and maintenance of overweight and obesity. We provide population-based norms for cognitive restraint, uncontrolled eating, and emotional eating as measured by the Three Factor Eating questionnaire (short form, TFEQ-18) in a UK cohort of middle-aged adults (the Fenland Study). Participants included 7830 individuals recruited across Cambridgeshire General Practices; 51.8% identified as female and participants reported a mean BMI of 26.8. Unadjusted linear regression estimated demographic (sex, age) and anthropometric (Body Mass Index, BMI) associations with each EBT to identify subgroups to derive normative scores. Percentiles of each EBT were calculated for the overall population and subgroups. Males scored lower than females on cognitive restraint (β=-7.86, 95% CI [-8.69, -7.03], p<0.001), uncontrolled eating (β=-1.03, 95% CI [-1.80, -0.26], p=0.008), and emotional eating (β=-13.13, 95% CI [-14.28, -11.98], p<0.001). Older age was associated with higher scores on cognitive restraint (β=0.13, 95 % CI [0.07, 0.19], p < 0.001), and lower scores on uncontrolled eating (β=-0.34, 95% CI [-0.39, -0.28], p<0.001) and emotional eating (β=-0.13, 95% CI [-0.21, -0.04], p=0.002). Higher BMI was associated with higher emotional eating (β=1.71, 95% CI [1.59, 1.83], p<0.001) and uncontrolled eating (β=1.05, 95% CI [0.97, 1.12], p<0.001). BMI was not associated with cognitive restraint. Normative scores provide context for individual EBT scores and may inform development, refinement, and application of prevention strategies for overweight, obesity, and eating disorders.

At present, no disease-modifying therapies are available for individuals who have been newly diagnosed with type 1 diabetes, despite promising results from decades of clinical trials initiated at stage3 disease onset. Historically, clinical trials have used changes in the C-peptide AUC (AUCCp) during a mixed meal tolerance test (MMTT) as the primary endpoint; however, this measure does not always correlate with clinical outcomes. We analysed 4930 MMTT data points from 799 participants in nine PhaseII stage3 type 1 diabetes trials to determine whether a model-derived physiological measure of in vivo beta cell glucose sensitivity (βGS) could augment clinical trial strategies in type 1 diabetes. Older age and higher BMI were associated with maintenance of βGS (defined as loss <10% of the baseline value) and maintenance of HbA1c <53 mmol/mol (7.0%). Baseline βGS, age, HbA1c and insulin dose together predicted the magnitude of the effect on HbA1c following intervention. When positive and negative trials were compared, normalised βGS served as an earlier indicator of trial efficacy compared with AUCCp. Our results identified thresholds of change in βGS associated with a clinically significant impact on glycaemic management after intervention and suggest that baseline βGS in association with clinical and demographic parameters may be applied to identify individuals who are more likely to respond to an intervention.

Surgical treatment of occipital headaches involves the decompression of the peripheral occipital nerves. While the literature extensively describes the longitudinal midline incision approach, our group initially used the longitudinal approach and switched to the transverse approach. The aesthetic outcomes of both incision techniques remain unexplored. Patients undergoing surgical decompression for occipital headaches were instructed to provide images of their exposed occipital scalp scar. Evaluation was conducted using the Stony Brook Scar Evaluation Scale (SBSES) and the Scar Cosmesis Assessment and Rating (SCAR) scale by 3 independent plastic surgeons. SBSES scores range from 0 to 5 (higher indicating better outcomes), while SCAR scores range from 0 to 15 (higher indicating worse outcomes). Comparisons were made between transverse and longitudinal scars, with factors influencing scores identified. Forty patients (average age: 47; 73% female) participated, with 28% having longitudinal midline scars and 72% having transverse scars. Patients with transverse scars exhibited higher SBSES scores (4.2 vs. 3.6; P = 0.044) and lower SCAR scores (3.0 vs. 4.6; P = 0.016). Longitudinal scar patients displayed more suture marks (SBSES: P =0.018; SCAR P = 0.003) and wider scar spread (SBSES: P = 0.013; SCAR: P = 0.038) compared with transverse scar patients. On regression analysis, higher BMI was associated with worse SCAR scores ( P =0.015), and a transverse scar was associated with improved SCAR scores ( P =0.008). Our study reveals superior aesthetic outcomes with the transverse incision approach for occipital nerve decompression surgery compared with the longitudinal midline technique. Transverse scars exhibited higher SBSES scores and lower SCAR scores, indicating better cosmesis. Notably, longitudinal scars were associated with more prominent suture marks and wider scar spread.

Predictors associated with failing to achieve a patient-acceptable symptom state in the Oxford Knee Score following total knee arthroplasty.

Metabolic dysfunction (MetD) and alcohol use disorder (AUD) frequently coexist as synergistic risk factors for steatotic liver disease. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are established therapies for MetD, including type 2 diabetes mellitus (T2DM) and obesity. Recent studies suggested potential beneficial effects of GLP-1RA to decrease addictive behaviours in AUD. We evaluated the outcomes of GLP-1RA therapy compared with FDA-approved pharmacotherapies for AUD, including naltrexone, acamprosate, and disulfiram, in patients with dual risk factors of MetD and AUD. We conducted a retrospective cohort study of patients at Stanford Health Care (2017-2025). Eligible patients had a concurrent diagnosis of alcohol-related complications meeting criteria for AUD and MetD, including obesity (BMI > 25) and/or a history of T2DM with HbA1c > 5.7. Those with advanced liver disease within 1 year of diagnosis were excluded. Exposure groups included ≥ 6 months of GLP-1RA therapy (semaglutide or tirzepatide) in comparison with FDA-approved pharmacotherapies for AUD. Propensity score matching was employed to reduce the effects of confounding factors. In total, 1946 patients were diagnosed concurrently with AUD and MetD. Of them, 274 patients were exposed to GLP-1RA, 1272 to naltrexone, 232 to acamprosate, and 168 to disulfiram. Patients were followed for an average of 1341 days. Patients exposed to GLP-1RA had higher BMI (35.5 vs. 30.1) and more T2DM (66% vs. 14%). GLP-1RA therapy was associated with lower 1-year AUD relapse [IRR 0.55, 95% CI 0.42-0.73; p < 0.01], greater BMI reduction (-1.3 vs. -0.3; p = 0.004), and HbA1c improvement (-1.0 vs. +0.1; p = 0.02). The incidence of decompensated cirrhosis trended lower but was not statistically significant [HR 0.52, p = 0.09]. Mortality was similar. GLP-1RAs are a promising option for patients with concurrent MetD and AUD, improving relapse rates and metabolic outcomes compared with currently FDA-approved pharmacotherapies for AUD. Trends toward better liver outcomes support further prospective evaluation.

Global patterns and risk factors of breast cancer in women under 35: a population-based study.

This review evaluates whether pregestational prediabetes identifies women at risk of subsequent gestational diabetes mellitus (GDM) and examines its association with maternal and offspring outcomes. Prediabetes is common in women of reproductive age and often precedes GDM. The risk factors for prediabetes and GDM are similar, such as higher BMI, polycystic ovary syndrome, advancing age, and genetic susceptibility. Both conditions denote underlying insulin resistance with limited beta-cell reserve. Preliminary evidence indicates that women with pregestational prediabetes have a higher likelihood of developing GDM. Risk rises progressively with increasing glycemia. Prediabetes is also associated with modestly increased risks of hypertensive disorders of pregnancy and preterm birth, though associations with cesarean delivery, macrosomia, and neonatal outcomes are inconsistent. Glycated hemoglobin in the prediabetes range early in pregnancy is associated with a higher risk of progression to type 2 diabetes than GDM diagnosed at 24-28 weeks. These observations support the view that pregestational prediabetes may emerge as an early marker of metabolic risk with implications extending beyond pregnancy. Prediabetes represents a state of increased metabolic risk in women planning pregnancy. It lies along a dysglycemic continuum linking preconception glycemic status to GDM and future diabetes. Incorporating glycemic assessment into preconception care may aid GDM risk stratification. However, the evidence is still evolving, and prospective studies are needed to define the role of pregestational prediabetes in predicting maternal, fetal, and long-term outcomes.

Low prolactin levels during pregnancy have been linked to adverse maternal metabolic health. We examined pregnancy prolactin levels in relation to maternal metabolic characteristics within an ethnically diverse cohort at high metabolic risk. In this observational cohort study, pregnant women (n = 130) with metabolic risk factors were characterized in early pregnancy, with sampling of serum prolactin and metabolic parameters. Fifty-four women with gestational diabetes consented to serial profiling across pregnancy. Univariable and multivariable simple and mixed-effects regression models examined relationships between prolactin and maternal variables. Women with obesity (BMI ≥30 kg/m2) had lower early pregnancy prolactin levels than women without obesity (35.1 vs 44.3 μg/L, p = 0.03). Lower prolactin in early pregnancy was associated with higher parity and higher early pregnancy BMI, fasting insulin, insulin resistance, and diastolic blood pressure, but only relationships with parity and BMI persisted after adjustment for covariates. In the serially sampled cohort, lower prolactin levels across pregnancy were independently associated with higher pre-pregnancy maternal BMI (adjusted β = -3.25, p = 0.04). Lower absolute prolactin increment from early to late pregnancy was independently associated with higher pre-pregnancy and early pregnancy maternal BMI (p = 0.046 and p = 0.04, respectively). Maternal metabolic status, particularly higher BMI before and during early pregnancy, was associated with lower prolactin levels in early pregnancy and across gestation, and a smaller prolactin increase over pregnancy. Lower prolactin levels may reflect underlying metabolic health and may be relevant to the suboptimal lactation outcomes observed in women with obesity and metabolic disease.

To evaluate long-term shoulder outcomes after sentinel lymph-node biopsy (SLNB) versus axillary lymph-node dissection (ALND) and identify predictors of chronic shoulder dysfunction. This prospective multicenter study enrolled 1111 women (≥ 18 years) undergoing breast cancer surgery with SLNB (n = 931) or ALND (n = 180) across five tertiary hospitals between October 2022 and June 2024. Functional outcomes were assessed using QuickDASH, range-of-motion (ROM), daily-activity limitations, pain, axillary web syndrome (AWS), and lymphedema. Multivariable regression identified independent predictors of poor shoulder function. ALND was associated with consistently greater morbidity. Mean QuickDASH scores were 17.1 ± 10.5 after ALND versus 11.5 ± 9.8 after SLNB (p < 0.001). ROM limitation (38.3% vs. 20.0%), reduced daily-activity performance (41.1% vs. 23.1%), AWS (13.9% vs. 7.0%), and lymphedema (16.1% vs. 4.2%) were all more frequent after ALND (p ≤ 0.002). Pain intensity was higher (2.28 ± 2.82 vs. 1.31 ± 2.11; p < 0.001). In multivariable analysis, ALND (β = 1.18, p < 0.001), higher BMI (β = 0.27, p = 0.001), and depressive disorders (β = 0.31, p < 0.001) independently predicted worse shoulder function; age and physiotherapy timing were not significant. Functional deficits persisted across lumpectomy and mastectomy subgroups. ALND is associated with greater long-term shoulder dysfunction compared with SLNB. Obesity and depressive symptoms exacerbate morbidity, highlighting the importance of comprehensive survivorship rehabilitation. ClinicalTrials.gov identifier: NCT05950685.

Prepectoral breast reconstruction with polyurethane (PU)-coated implants has been proposed to enhance implant stability and reduce complications. Evidence regarding their clinical and aesthetic performance remains limited. A retrospective review was performed on 117 patients (186 breasts) who underwent immediate prepectoral reconstruction with PU-coated implants between 2020 and 2025. Complications were analyzed with univariate and multivariable regression. Aesthetic outcomes were evaluated using BCCT.core software. At a median follow-up of 15months, 34 patients (29.1%) experienced at least one complication, most commonly rippling or upper-pole visibility (16.2%). Implant loss occurred in 3.4% and capsular contracture in 1.7%. Higher BMI, larger implant size, and skin-reducing mastectomy were associated with increased complication risk, although none remained independently significant. Chemotherapy had no measurable impact, and radiotherapy showed only a mild trend toward poorer aesthetic scores. Overall, 81.2% of patients achieved excellent or good BCCT.core results. Younger age and absence of complications were the strongest predictors of favorable aesthetic outcomes. PU-coated implants provided stable outcomes in prepectoral reconstruction, with low implant loss and rare contracture. Most patients achieved favorable cosmetic results without the need for additional reinforcement materials. Higher BMI, larger implants, smoking, and skin-reducing mastectomy increased complication risk primarily in univariate analyses. Prospective multicenter studies with longer follow-up and patient-reported outcomes are required to validate these findings. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

To compare the perioperative outcomes, postoperative complications, and oncologic results between robotic-assisted and laparoscopic rectal cancer surgeries in patients with high BMI. A meta-analysis was conducted under the PRISMA guidelines. PubMed, SCOPUS, Embase, and Cochrane Library databases were searched from inception to May 2025 for studies comparing robotic and laparoscopic rectal cancer surgeries among patients with BMI ≥ 28kg/m2. Five studies included data for 700 cases in the robotic group (RG) and 2102 cases in the laparoscopic group (LG). The main areas of outcome investigations included operative time, length of hospital stay (LOHS), conversion rates, overall postoperative complications, and harvested lymph nodes. Pooled estimates were analyzed using the random-effect models. The pooled analysis of five studies showed that the robotic group had a significantly shorter hospital stay and a lower conversion rate than the laparoscopic group (P < 0.05), while operative time was approximately 30min shorter in the laparoscopic group (P < 0.05). Following exclusion of Zhao 2024, subanalysis of the remaining four studies demonstrated that the laparoscopic group still had a significantly shorter operative time and the robotic group maintained a significantly lower conversion rate; however, a significant difference in hospital stay was no longer present, and no significant differences were found for harvested lymph nodes or postoperative complications. No major difference was observed concerning lymph node yield and readmission rates between the surgical measures. Robotic surgery was associated with a significantly lower conversion rate, whereas laparoscopic surgery was associated with significantly shorter operative times; no consistent advantage was observed for hospital stay, as this finding was not replicated in sensitivity analysis. Further high-quality studies are warranted to confirm these results.

Enhanced Recovery After Surgery (ERAS) in Pancreatic Surgery: A Comparative Systematic Review of Global Practices, Compliance Variation, and Clinical Outcomes.

Cathepsin G (CTSG) is a neutrophil-derived serine protease implicated in inflammatory pain modulation. Genetic variation in CTSG may influence postoperative pain susceptibility. This study evaluated the association between CTSG polymorphisms, CTSG plasma concentration and enzymatic activity, and long-term pain after cardiac surgery. We conducted a prospective cohort study including 255 Caucasian adults undergoing elective cardiac surgery via median sternotomy. CTSG single nucleotide polymorphisms (SNPs) rs2070697, rs2236742, and rs45567233 were genotyped. A random subsample of 107 patients underwent measurement of CTSG plasma concentration and enzymatic activity. Pain intensity (visual analogue scale [VAS]) at rest and with movement was assessed at 24 hours, 1 month, 6 months, and 12 months. Ordinal logistic regression was used to analyze associations between CTSG variants and pain. Mendelian randomization evaluated the causal effect of CTSG activity on pain. Overall, 16/250 patients (6.4%) reported moderate to severe postsurgical pain during movement at 6 months, and 6/178 patients (3.3%) at 12 months. At 1 month, pain was associated with higher BMI (P = .016); at 12 months, it was more frequent in women (P < .001) and in patients using antidepressants (P = .022). The rs2070697 AA genotype was associated with reduced pain at 1 month at rest (GA vs AA: OR = 4.329, 95%CI = 1.523-12.310, P = .006), 6 months at rest and in movement (GA vs AA at rest: OR = 4.642, 95%CI = 1.535-14.040, P = .007; GA vs AA in movement: OR = 3.509, 95%CI = 1.169-10.530, P = .025), and 12 months in movement (GA vs AA: OR = 5.754, 95%CI: 1.492-22.200, P = .011). In contrast, the rs2236742 AA genotype was associated with increased pain at all three time points (P < .05). Carriers of rs2236742 AA also reported greater preoperative informational anxiety (GG vs AA: OR = 0.193, 95%CI: 0.049-0.758, P = .018). CTSG activity was lower in rs2070697 A-allele carriers (P = .03). CTSG activity and pain showed no causal association. No significant relationships were found for rs45567233. Variants appear to modulate susceptibility to prolonged post-sternotomy pain. These findings warrant validation in larger multi-ethnic cohorts to clarify mechanisms and potential implications for personalized perioperative pain management.

Type 1 diabetes stigma (T1D-stigma) refers to negative social judgement towards people living with type 1 diabetes (T1D) and is linked to poorer psychological well-being and suboptimal diabetes self management. This observational study aimed to explore sociodemographic, diabetes health and well-being factors linked to high stigma scores to inform future, targeted intervention studies. UK-based adults (aged ≥18 years) with T1D completed an online survey comprising sociodemographic and diabetes health questions, wellbeing measures for anxiety (Generalised Anxiety Disorder Scale: GAD-7), diabetes impact (Impact of Diabetes Profile: DIDP) and depression (Patient Health Questionnaire: PHQ-9) and the Type 1 Diabetes Stigma Assessment Scale (DSAS-1). Potential relationships between sociodemographic, diabetes health and well-being factors and DSAS-1 score were identified by univariate regression and the independence of significant (p < 0.05) relationships was explored in multivariable regression. Of 438 participants, 96% endorsed one or more items on the DSAS-1. In multivariable regression, age (β = -0.136, p = 0.006), sex (β = 0.114, p = 0.006), BMI (β = 0.112, p = 0.023), insulin pump use (β = 0.108, p = 0.015), DIDP score (β = 0.211, p = <0.001), GAD-7 score (β = 0.192, p = 0.002) and PHQ-9 score (β = 0.195, p = 0.002) predicted DSAS-1 score. Ethnicity did not predict DSAS-1 score, nor did age at diagnosis or number of severe hypoglycaemia episodes. Most participants reported at least one instance of T1D-stigma. High DSAS-1 scores in the United Kingdom were predicted by younger age, being a woman, higher BMI, insulin pump use, higher diabetes impact and anxiety and depression scores. Future studies should further explore the impact of T1D-stigma within these groups to tailor appropriate interventions.

Despite its rising prevalence, older adults with Type 1 diabetes remain poorly characterised. This study aimed to characterise those over 60 years and quantify independent predictors of glycaemic control and complications. We performed a multicentre analysis using real-world data from the China Diabetes Type 1 Study (CD1S), including 69 centres across China between 2016 and 2021. Patients were stratified into three age groups (≥ 60, 18-59 and < 18 years) for assessment of clinical characteristics and complications. Multiple regression examined associations of clinical features with HbA1c and complications. Variable importance was interpreted using SHAP values derived from a random forest model. We enrolled 9637 patients with Type 1 diabetes. Compared with young adults, older adults with Type 1 diabetes were less likely to achieve target HbA1c (7.2% vs. 10.2%, p < 0.05) and had a substantially higher burden of chronic complications, with 81.0% of older adults having at least one complication. Longer duration, higher BMI and higher gross domestic product (GDP) were significantly associated with lower HbA1c (all p < 0.05). Higher GDP was linked to reduced rates of diabetic retinopathy (19.7%), nephropathy (13.6%) and peripheral neuropathy (46.9%), yet a higher proportion of peripheral vasculopathy (41.8%) was observed compared with middle- and low-GDP regions. Older adults with Type 1 diabetes exhibit a unique clinical profile of poor glycaemic control and a high burden of complications, influenced by regional GDP disparities. This underscores the critical need to integrate socioeconomic factors into personalised care strategies to advance health equity. NCT05498974.

Older adults receiving home healthcare services represent a highly vulnerable group for functional decline. This study aimed to determine the prevalence of malnutrition and sarcopenia in this population, investigating their relationship with quality of life (QoL). This cross-sectional study was conducted between February 2024 and February 2025 among 254 older adults (≥65 years) receiving home healthcare in Balıkesir, Türkiye. The region was selected for its high elderly population ratio (16.9%), significantly exceeding the national average (10.6%). Nutritional status was assessed using the Mini Nutritional Assessment-Short Form (MNA-SF), sarcopenia risk with the SARC-F (Strength, Assistance with walking, Rise from a chair, Climb stairs, and Falls) scale, and QoL with the CASP-19 (Control, Autonomy, Self-realization, and Pleasure) scale. Anthropometric measurements (Body Mass Index [BMI], mid-upper arm circumference [MUAC], and calf circumference [CC]) were recorded. Malnutrition was identified in 32.7% of participants, while 58.3% were at risk. The risk of sarcopenia was high at 90.2%. Participants with malnutrition and sarcopenia risk had significantly lower QoL scores (p < 0.001). Better nutritional status, higher BMI, and greater MUAC and CC measurements were positively associated with higher QoL (all p < 0.001). Correlation analysis revealed significant negative relationships between nutritional status and sarcopenia risk (r = -0.33, p < 0.001) and between sarcopenia risk and QoL (r = -0.46, p < 0.001). Malnutrition and sarcopenia risk frequently coexist in home healthcare settings and are strongly associated with lower QoL. Routine nutritional and functional screening are essential in home care to facilitate early intervention and improve well-being in this vulnerable population.

Prevalence, trends, and determinants of early-onset type 2 diabetes in northwest China: a sex-stratified analysis of ∼10 million community-dwelling population.

Hidden blood loss (HBL) is an underrecognized contributor to total perioperative blood loss after hip fracture surgery. This study aimed to quantify HBL during the first three postoperative days following proximal femur fracture fixation and to assess the impact of preoperative anticoagulant therapy on blood loss and transfusion requirements. A retrospective cohort study was conducted including patients aged ≥ 65 years who underwent surgical fixation of proximal femur fractures at a level I trauma center between January 2020 and December 2022. Total blood loss was estimated from perioperative hemoglobin changes and calculated blood volume. Patients were stratified according to anticoagulant use, and logistic regression analysis was performed to identify independent predictors of increased blood loss. Among 260 patients analyzed, median total blood loss was 1184ml, and 25% experienced losses exceeding 1675ml. High blood loss correlated significantly with anticoagulant use, higher BMI, and longer operative time (p < 0.001). In multivariate analysis, anticoagulant therapy (particularly direct oral anticoagulants) remained an independent predictor of high blood loss (OR 3.06; 95% CI 1.47-6.37; p = 0.003). Patients in the highest quartile required significantly more transfusions, though short-term mortality did not differ. Hidden blood loss after proximal femur fracture surgery is frequent and clinically relevant. Anticoagulant use, elevated BMI, and prolonged operative duration independently increase bleeding risk. Awareness of these predictors may support optimized perioperative management and transfusion planning in elderly fracture patients.

Anastomotic stricture (AS) is a common late complication after esophagectomy. Evidence guiding endoscopic escalation ("step-up") and the risk of post-treatment recurrence remains limited. We assessed clinical, surgical, and procedural determinants of (i) need for step-up therapy and (ii) recurrence after initial endoscopic success. We conducted a multicenter retrospective study at two tertiary centers in Milan (2014-2024). Adults with naïve post-esophagectomy AS underwent standardized endoscopic management (bougie or pneumatic dilatation with predefined step-up options: incision therapy, stenting, steroid injection). Outcomes included technical (TS) and clinical success (CS), safety, rates of step-up and recurrence, and uni/multivariable predictors of change of strategy and recurrence. Among 1729 esophagectomies, 61 patients (3.5%) developed benign AS. Initial therapy was bougie in 54.1% and pneumatic in 45.9%. TS was achieved in 100% and CS in 93.4%. Safety was favorable (1/61, 1.6%). Overall, 39.3% required a change of strategy, typically early: the first switch occurred at a median of 35days, and in 62.5% within 30days, most often for failure to achieve a ≥ 2-mm lumen gain (66.7%). On multivariable analysis, higher BMI (OR 0.81 per 1kg/m2, p = 0.022) and baseline dysphagia < 2 (OR 0.13, p = 0.006) independently reduced the likelihood of step-up. Among patients with CS, recurrence occurred in 24.6% (14/57). In models restricted to surgical variables, stapled versus hand-sewn anastomosis was protective (OR 0.11, p = 0.022), whereas procedure type (McKeown vs Ivor-Lewis) and caliber ≤ 25mm were not significant. Endoscopic treatment of post-esophagectomy AS is highly effective and safe, yet step-up intervention is required in nearly 40% and recurrence occurs in one quarter of patients. Nutritional status and baseline dysphagia help identify patients at higher risk of escalation, while stapled anastomoses appear to reduce recurrence. These findings support a risk-adapted, personalized endoscopic strategy and warrant prospective validation.