Management Options Research Articles

Penile compression devices for the treatment of urinary incontinence: current status and future prospects.

Urinary incontinence (UI), especially stress UI, is common after prostatectomy. Penile compression devices (PCDs) may be a safe, tolerable option for conservative management in men who are not candidates for or not interested in surgical intervention for their UI. This article examines the epidemiology of post-prostatectomy urinary incontinence (PPI), and options for management. All available studies on PCDs are explored, including those on biomechanics, safety, tolerability, and user experience. History, availability of PCDs, and areas for future development are discussed. PCDs are an option for conservative management of PPI. They are recommended for those men without impairment in cognition, dexterity, or sensation. They should be worn for short periods of time and are best used during situations when incontinence might be precipitated. Overall, data suggest they are well tolerated and effective when tested, but large randomized comparative trials and studies of long-term use with relevant patient reported outcome measures are lacking. More studies are needed on commercially available PCDs. Biomechanical studies suggest that there are superior designs and materials both for efficacy and tolerability. With an aging population, and more older men going for prostate surgery, a larger market for these devices is likely.

Current understanding of subjective tinnitus in adults.

An up-to-date overview of epidemiology, etiology and pathophysiological mechanisms, diagnostic and evaluation methods, current treatment status and future directions of subjective tinnitus in adults. Review of current evidence-based literature on subjective tinnitus in adults. The prevalence of subjective tinnitus in the adult population is estimated to be around 14%, and it tends to increase with age. Subjective tinnitus is a complex condition with multiple factors contributing to its origin. However, the exact causes and underlying mechanisms remain unknown. Potential causes may include hearing loss, dysfunction in the somatosensory system, and auditory cortical dysfunction, although severe underlying pathology is rare. Currently, diagnosis primarily relies on patient self-reported medical history and physician-based clinical assessment due to the lack of objective testing. Various treatment and management options have been proposed, but their effectiveness varies, and there is no universally agreed-upon treatment option. Tinnitus is a complex and heterogeneous disease with a high incidence rate and a tendency to increase with age. A holistic perspective is needed to understand the generation, perception, and emotional responses to tinnitus. Diagnosis requires a comprehensive assessment based on medical history and relevant examinations, identification of concurrent psychosomatic comorbidities, and active pursuit of objective diagnostic methods. At the same time, on the basis of existing treatment plans and combining emerging technologies, we will develop new personalized, precise, and combined treatment plans.

Cardiovascular Risk in Rheumatoid Arthritis: Considerations on Assessment and Management.

In the context of holistic therapeutic practices, the cardiovascular risk of patients with rheumatoid arthritis (RA) needs to be addressed as a major factor of compromised disease prognosis and increased mortality. The elevated prevalence of cardiovascular disease (CVD) by more than twofold in RA has been attributed, inter alia, to chronic inflammation exacerbating arterial stiffness, increased onset of hypertension, dyslipidaemia and diabetes mellitus, sedentary lifestyle, and antirheumatic drug complications. CVD risk in RA can be currently assessed by practitioners through accessible adapted calculators, but it remains problematic as their diagnostic accuracy is not superior to calculators designed for the general population. Implementation of guideline-oriented personalised interventions remains the cornerstone for cardiovascular risk management in RA. Remarkably, there is lack of a consortium that brings together different health care providers engaged in the care of patients with RA (e.g., rheumatologists, cardiologists, general practitioners, etc), to guide cardiovascular risk assessment and management. This narrative review aims at providing an overview of current CVD risk assessment and management options, highlighting their pivotal role in the comprehensive treatment of RA patients.

A Comparative Analysis of Botulinum Toxin Use Versus Other Therapies for Temporomandibular Disorders: A Systematic Review.

Existing literature regarding the efficacy of Botulinum toxin A (BoNT-A) therapy in improving the clinical outcomes of temporomandibular disorders (TMDs) is ambiguous and lacks consistency. Thus, this study aimed to evaluate the efficacy of BoNT-A in reducing pain, occlusal force, electromyographic (EMG) changes, and maximum mouth opening compared with placebo and other interventions. An electronic database search was conducted using MEDLINE, PubMed, Google Scholar, the Cochrane Library, and ClinicalTrials.gov from January 2000 to June 2024 to identify randomized controlled trials (RCTs). A manual search complemented the electronic search. The Risk of Bias 2 (RoB 2) assessment was used to evaluate the internal validity of the included studies. A total of 1719 studies were identified, of which 23 fulfilled the inclusion criteria. Nineteen of these studies evaluated pain levels (primary outcome) after BoTN-A therapy, with six of them observing a decrease. In terms of secondary outcomes, seven of 10 studies noted an increase in maximum mouth opening, while all six reported a drop in EMG activity, and all four found a decrease in occlusal force following BoNT-A therapy.Muscle activity and biting force were significantly reduced in the therapeutic groups. Clinicians must consider these adverse events before treating patients with BoNT-A therapy. Additional regulatory guidelines and standardization of injection protocols are essential in improving therapeutic outcomes and patient safety. These findings suggest that BoNT-A may be a feasible option for TMD management but should be used with caution in clinical settings.

A Multicenter Prospective Sham-controlled Trial Evaluating a Physiologic Closed-loop Wearable Tibial Neuromodulation System for Overactive Bladder

ObjectiveTo evaluate the effectiveness and safety of a home-based, physiologic closed-loop wearable tibial neuromodulation system in comparison to a sham control for the treatment of Overactive Bladder (OAB). MethodsThis multicenter, prospective, randomized, double-blind, sham-controlled trial included 125 adult subjects with OAB who were randomized 1:1 to receive either active therapy with the Vivally System or sham therapy. Patients were allowed to continue concomitant OAB medications if therapy was stable and the remained on a consistent regimen throughout the study. The primary efficacy endpoint was a responder rate, defined as ≥50% reduction in daily urgency leaks or a ≥30% reduction in daily voids from baseline recorded on an electronic voiding diary. Safety was evaluated through adverse event (AE) reporting and patient satisfaction with the system was recorded. ResultsIn the the modified Intent-to-Treat (mITT) population (n=107) the responder rate was significantly higher in the active therapy arm (83.6%) compared to the sham arm (57.7%; p=0.032). The system demonstrated a favorable safety profile with no serious AE. Patient satisfaction with the device and mobile application was high with 90/92 (97.8%) reporting they were moderately to extremely satisfied and therapy compliance was above 92% for both therapy and sham groups. ConclusionThe Vivally System showed significant improvement in OAB symptoms compared to sham therapy, demonstrating a high responder rate and excellent safety profile. The combination of physiologic closed-loop neuromodulation and a behavior-tracking application may offer an effective and user-friendly option for OAB management.

Management of Psychiatric Diagnoses in Reversible Cerebral Vasoconstriction Syndrome: The Dangers of Worsening Pathology with Serotonergic Medications: A Case Report and Literature Review.

Reversible cerebral vasoconstriction syndrome (RCVS) represents a group of conditions that show reversible multifocal narrowing or constriction of the cerebral arteries that supply blood to the brain. The initial manifestation of RCVS often includes a "thunderclap" headache that is sudden, severe, and often disabling. Stimulants, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and antipsychotics with serotonergic activity can alter the cerebral arterial tone, trigger vasoconstriction, and place patients at risk of a cerebrovascular accident. Thus, psychiatric medications are commonly discontinued on admission for RCVS, and psychiatry is often consulted for input on acute medication management and longitudinal treatment options. Currently, there is a dearth of literature on managing psychiatric medications in RCVS, resulting in variable practice patterns that place patients at risk of withdrawal, decompensation, and relapse. In this article, we provide a case example and aim to consolidate the limited data surrounding the management of psychiatric illness with comorbid RCVS in our discussion. There is a clear concern about worsening and even potentially lethal consequences due to serotonin or stimulant-induced vasospasm both during an acute episode and in long-term management of RCVS. We discuss the underlying pathophysiologic mechanisms proposed for serotonergic-, noradrenergic-, and dopaminergic-induced cerebral vasospasm and how this correlates with the clinical management of patients on psychiatric medications. These data will then be organized to create a risks versus benefits outline to equip psychiatrists to make decisions about when to stop and when to restart psychiatric medications in the setting of RCVS.

327. INCIDENCE OF GASTRIC BAND REMOVAL: A REVIEW OF THE LITERATURE

Abstract Purpose In the wake of the global obesity epidemic, bariatric surgery has become critical to prevent the complications of obesity and reduce the impact across health care systems. Laparoscopic Gastric Band insertion was at one point the most performed bariatric operation for obesity. In Australia, due to the limited publicly funded bariatric units, LAGB insertion is often performed in the private health sector. However, the post operative course for many of these patients who underwent LAGB has been fraught with complications often resulting in presentation to emergency, explantation of the LAGB and further surgical intervention. and is considered unfavourable in management of obesity. Methodology We performed a search of medical subject headings within PubMed, Medline and Embase for the terms ‘Gastric Band*’, ‘remov*’, ‘explant*. Following removal of duplicates, a total of 46 articles detailing the incidence of gastric band removals. Studies were included if they included discrete cohorts of patients who have undergone LAGB insertion, reported data on incidence of removal and median follow up >3 years. Results Results of the literature review will be discussed. Conclusion While it is considered unfavourable as a surgical option for management of obesity, public hospitals continue to absorb many patients who have undergone this procedure placing stress on an already stretched system. The incidence of LAGB varies in the literature. The authors would like to provide an updated review of the literature to determine the incidence of LAGB to better inform patients and health care providers.

Physician practices in referring rheumatoid hand and thumb carpometacarpal arthritis cases to hand surgeons.

To investigate the referral practices across different medical specialties and identify possible barriers to hand surgery referral. Rheumatoid hand deformities (RHDs) and thumb carpometacarpal (CMC) arthritis may require surgery once deformities occur. However, in Saudi Arabia, the rate of referrals to hand surgeons remains low. This was a cross-sectional study that included 102 consultants of family medicine, rheumatology, and orthopedics across various regions of Saudi Arabia. A total of 30 institutions were contacted and requested to distribute a survey questionnaire to their physicians; these institutions included 8 private hospitals, 16 government hospitals, and 6 primary healthcare centers. The survey included questions on the incidence, rate, management, knowledge, and referral of patients with RHD and CMC arthritis using a 5-point Likert scale. The Kruskal-Wallis H test was utilized in our analysis to evaluate the differences in responses among the 3 specialties. For RHD and thumb CMC arthritis, the referral rate was higher among orthopedic surgeons compared to rheumatologists and family medicine physicians. The main barriers to referral were patient refusal, medical treatment alone being deemed adequate, and a lack of awareness of surgical options for management. Our findings highlight discrepancies in patterns of physician referral of RHD and thumb CMC arthritis cases to hand surgeons, indicating the need for targeted interventions to improve referral rates and enhance patient outcomes.

Microbial spectrum, management challenges, and outcome in patients with otogenic skull base osteomyelitis.

The study aimed to explore the spectrum and trend of causative microbial agents and to identify management challenges and the risk factors for poor outcomes in patients with confirmed otogenic skull base osteomyelitis. A retrospective observational study was conducted at a tertiary-care academic center from 1999 through 2019 and included 28 adult patients with confirmed otogenic skull base osteomyelitis. Relevant data was extracted from electronic and hard patient medical files. The microbial spectrum of involved microbes was identified and correlated to management options. Deterioration risk factors were investigated using suitable statistical analysis tests. Twenty-eight patients with confirmed skull base osteomyelitis were included; most were males (78.6%) and Saudis (78.6%). All patients were ≥50 years of age (mean ± SD is 69.0±10.2.4). Of 41 identified microbial isolates, 56% were bacterial, 44% were fungal. 32.1% of patients had polymicrobial infections, most patients (92.8%) had received ≥2 systemic antibiotics, 57.1% received systemic antibiotic combinations, and 32.1% underwent surgical interventions. The mean antibiotic and antifungal therapy duration was 58.3 and 45.8 days, respectively. The identified risk factors of deterioration were advanced age and concomitant cardiac failure, with P-values of .006 and .034, respectively. The study findings highlight the microbiological spectrum and trend of otogenic skull base osteomyelitis-causative microbes over two decades, present the management challenges, identify deterioration risk factors, and suggest tissue biopsy as the golden standard for accurately identifying causative microbes.

Low Genetic Variation Contrasts With Variable Morphotypes in Neoscytalidium dimidiatum From the Philippines and Their Aggressiveness to Dragon Fruit Species

ABSTRACTNeoscytalidium dimidiatum is an asexual, opportunistic and necrotrophic pathogen that causes the devastating stem canker disease of dragon fruit species (Selenicereus spp.). Despite this, information about its intraspecific diversity remains lacking. Examination of the morphological variations of 40 N. dimidiatum isolates hosted by S. megalanthus, S. monacanthus and S. undatus from eight allopatric regions in the Philippines detected three distinct morphotypes. Sequencing of three partial gene markers (ITS, ACT and TUB2) of representative isolates revealed low intraspecific genetic diversity of the pathogen from the three hosts. Phylogenetic analysis of internal transcribed spacer (ITS) sequences of the isolates in this study and worldwide collections of the phytopathogen in the GenBank database infers similar founding populations and the possible specificity of the dragon fruit‐infecting N. dimidiatum. Pathogenicity and aggressiveness assay of the isolates on detached stems of dragon fruit did not detect host specificity to S. monacanthus and S. undatus. However, some isolates (i.g., MBDF0802A, MBDF0808B, MBDF0339A and MBDF0007A) significantly had shorter latent period to the stems of S. undatus than S. monacanthus. A higher aggressiveness component of lesion size development on S. undatus stems by isolates from S. monacanthus was recorded suggesting a possible directional selection of highly aggressive N. dimidiatum in this host. This is the first population study on the phenotypic traits and the genetic structure of N. dimidiatum. Valuable inputs for further study of the pathogen are provided, which may help inform the design of management options for stem canker disease of dragon fruit.

USE OF SOLENSIA (FRUNEVETMAB) IN NONDOMESTIC FELIDS (PANTHERA TIGRIS, LYNX RUFUS, PANTHERA UNCIA) GUIDED BY PROTEIN SEQUENCE ANALYSIS.

Osteoarthritis and degenerative joint disease affect many species of nondomestic felid and negatively impact quality of life in managed care settings. Previously, pain management options were limited because of the frequency of comorbidities such as renal disease and common difficulty encountered in medication administration. SolensiaTM (frunevetmab) is a felinized monoclonal antibody that binds to nerve growth factor in arthritic joints, thereby inhibiting pain response cascades, and produces marked improvement in clinical signs and quality of life in domestic cats diagnosed with osteoarthritis. Protein sequence analysis was performed to inform the application of frunevetmab in four individuals from three nondomestic felid species (Panthera tigris, Lynx rufus, and Panthera uncia) diagnosed with degenerative joint disease to predict safety, contraindications, and likely response to treatment. Patients were then treated utilizing doses extrapolated from domestic cats and following manufacturer guidelines for administration, and clinical response was evaluated over a minimum 2-mon period. Significant improvement was noted in clinical signs in all four animals, resulting in marked improvement in mobility, lameness, activity level, demeanor, and overall quality of life. Frunevetmab presents an excellent adjunctive therapeutic alternative for nondomestic felids suffering from degenerative joint disease and may complement or decrease the need for other conventional therapeutic regimens.

The influence of forest types including native and non‐native tree species on soil macrofauna depends on site conditions

AbstractThe ongoing climate change calls for managing forest ecosystems in temperate regions toward more drought‐resistant and climate‐resilient stands. Yet ecological consequences of management options such as planting non‐native tree species and mixing coniferous and deciduous tree species have been little studied, especially on soil animal communities, key in litter decomposition and pest control. Here, we investigated the taxonomic and trophic structure of soil macrofauna communities in five forest types including native European beech (Fagus sylvatica), range‐expanding Norway spruce (Picea abies) and non‐native Douglas fir (Pseudotsuga menziesii) as well as conifer‐beech mixtures across loamy and sandy sites in northern Germany. Abundance of primary decomposers (feeding predominantly on litter) was high in Douglas fir and beech forests, benefiting from less acidic soil and more favorable litter resources compared to spruce forests, while secondary decomposers (feeding predominantly on microorganisms and microbial residues) reached highest densities in spruce forests. Differences in abundance and species richness among forest types generally varied between regions and were most pronounced in Douglas fir of the sandy region. However, trophic guilds differed more between regions than between forest types, indicating that environmental factors outweigh the importance of forest type on soil macrofauna communities. The analysis of stable isotopes (δ15N and δ13C values) supported the general robustness in trophic position of macrofauna trophic guilds against variations in forest types and regions, but indicated reduced detrital shifts and food‐chain lengths in coniferous compared to European beech forests with mixtures mitigating these effects. Overall, for evaluating consequences of future forest management practices on the structure and functioning of soil animal communities, regional factors need to be considered, but in particular at loamy sites the taxonomic and trophic structure of soil macrofauna communities are resistant against changes in forest types.

The Use of Artificial Intelligence Technologies in Cancer Care

Artificial intelligence (AI) is already an essential tool in the handling of large data sets in epidemiology and basic research.Significant contributions to radiological diagnosis are emerging alongside increasing use of digital pathology. The future lies in integrating this information together with clinical data relevant to each individual patient. Linkage with clinical protocols will enable personalized management options to be presented to the oncologist of the future.Radiotherapy has the distinction of being the first to have a National Institute for Health and Care Excellence (NICE)-approved AI-based recommendation. There is the opportunity to revolutionize the workflow with many tasks currently undertaken by clinicians taken over by AI-based systems for volume outlining, planning, and quality assurance.Education and training will be essential to understand the AI processes and inputs. Clinicians will however have to feel confident interrogating the AI-derived information and in communicating AI-derived treatment plans to patients.

Primary antibody deficiencies.

Primary antibody deficiencies are characterized by the inability to effectively produce antibodies and may involve defects in B-cell development or maturation. Primary antibody deficiencies can occur at any age, depending on the disease pathology. Certain primary antibody deficiencies affect males and females equally, whereas others affect males more often. Patients typically present with recurrent sinopulmonary and gastrointestinal infections, and some patients can experience an increased risk of opportunistic infections. Multidisciplinary collaboration is important in the management of patients with primary antibody deficiencies because these patients require heightened monitoring for atopic, autoimmune, and malignant comorbidities and complications. The underlying genetic defects associated with many primary antibody deficiencies have been discovered, but, in some diseases, the underlying genetic defect and inheritance are still unknown. The diagnosis of primary antibody deficiencies is often made through the evaluation of immunoglobulin levels, lymphocyte levels, and antibody responses. A definitive diagnosis is obtained through genetic testing, which offers specific management options and may inform future family planning. Treatment varies but generally includes antibiotic prophylaxis, vaccination, and immunoglobulin replacement. Hematopoietic stem cell transplantation is also an option for certain primary antibody deficiencies.

Uterine Cancer: A Nine-year Review from a Tertiary Hospital in Tamil Nadu

Background: With increasing uterine cancer in developing nations, there is a need for timely determination of the diagnosis, prognosis, and management options to reduce morbidity and mortality. Objective: To analyze the socio-demographic, etio-pathological features and management of uterine cancer and evaluate its correlation with grading/staging in our population. Methods: This retrospective descriptive study analyzed data from 97 histologically proven uterine cancer cases. Age, parity, symptoms, co-morbidities, body mass index (BMI), ultrasound features, histopathology type, stage and grade of the tumor, type of hysterectomy done, complications and mortality were analysed. Statistical analysis was done using ANOVA and chi-square test, and a p-value<0.05 indicated statistical significance. Results: The mean age of diagnosis was 57.91 years, and the mean BMI was 29.32 Kg/m2. Majority of the patients were multiparous (42.27%), and only 10% were nulliparous. The disease was detected at an earlier age in nulliparous and obese women. Diabetes and hypertension were found in 75.25%. Most of the patients were detected with stage I cancer (80.6%). Patients diagnosed with uterine cancer on biopsy were treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy andbilateral pelvic lymph node dissection (55.8%). Over 36% of patients received postop radiotherapy and/or chemotherapy. 21% patients were lost to follow-up and 12.37% died. Also, 24 cases had postoperative complications (wound infection). Conclusion: Uterine cancer is common among obese women with diabetes and hypertension. In nulliparous and the obese, the cancer was detected at an earlier age. Most of our patients had stage 1 disease, and 90% was endometroid cancer. The study highlights the importance of endometrial sampling before hysterectomy in perimenopausal women to avoid suboptimal surgery in patients diagnosed with uterine cancer after a simple hysterectomy.

615. ROBOTIC REDO LAPAROSCOPIC HELLER’S CARDIOMYOTOMY

Abstract Introduction Robotic Heller’s cardiomyotomy is the preferred treatment option for achalasia cardia. However, following Heller’s cardiomyotomy up to 20% of patients experience dysphagia and regurgitation in the long term. The ideal management option for such patients needs to be determined. Surgical Steps The procedure is carried out with patient in supine position, legs abducted with the knees in slightly flexed position in reverse Trendelenburg position of approximately 30°.The pneumoperitoneum is created by closed Veress needle technique. After Relasing Adhesions, the gastrohepatic ligament is divided and the right crus is identified and retrocardiac window is formed; proximal short gastric vessels are divided for posterior wrap. The esophagus is separated by blunt dissection from the crus, the peritoneum and phrenoesophageal membrane are divided and the left crus is identified. If an anterior partial fundoplication is planned as antireflux procedure, the mobilization is limited to the lateral and anterior aspects. The anterior vagus nerve is identified and should be dissected and lifted away from the distal esophagus and proximal stomach in order to facilitate transhiatal dissection, myotomy and also to prevent injury to the esophagus and vagal trunks. Dissection is continued cranially around the esophagus for a distance of about 2–3 cm onto the dilated segment of the esophagus in the posterior mediastinum. If posterior partial wrap (Toupet) is planned, esophagogastric dissection is performed posteriorly from both crura and median arcuate ligament to get tension free wrap. Fundus of the stomach is dissected off the diaphragm and if needed two or three short gastric vessels are divided. Posterior vagal trunk is dissected along with esophagus. Conclusion Redo Robotic Heller’s cardiomyotomy can safely be performed with good symptomatic relief for patients who present with recurrent symptoms following Heller’s cardiomyotomy. Long term follow-up with larger sample size is needed to confirm these findings. https://drive.google.com/file/d/1uFgx0Aal92o5FE-Ndp-tAsCg01NJ6Crm/view?usp=sharing

Crop Residue Biochar Rather Than Manure and Straw Return Provided Short Term Synergism Among Grain Production, Carbon Sequestration, and Greenhouse Gas Emission Reduction in a Paddy Under Rice‐Wheat Rotation

ABSTRACTReturn of crop residues directly as straw, animal manure, or biochar are recommended management options for biowaste recycling and soil organic carbon (SOC) maintenance in agriculture. However, to address the soil health challenges associated with soil degradation and climate change, it is critical to determine if or which of these different forms of crop residues could deliver a synergic improvement in SOC storage, emission reduction, and crop productivity following field application. In this study, maize straw in the form of air‐dried biomass (CS), manure via cattle digestion (CM), and biochar via pyrolysis (CB) was respectively amended once at a dose of 10 t C ha−1, in comparison to no maize straw addition (CK), in a paddy field under rice‐wheat rotation. Changes in soil properties, SOC storage, greenhouse gas (GHG) emissions, and rice/wheat yield were examined over two consecutive rice/wheat rotation cycles following soil amendment. The total rice grain yield considerably increased by 6% under CM and CB, while it reduced by 6% under CS compared to CK. Soil nutrient content persistently increased under CM and CB by 4.2% ~ 17% and 11% ~ 26% for total nitrogen, 26% ~ 61% and 20% ~ 53% for available P, and 2% ~ 82% and 30% ~ 115% for available K, respectively. Topsoil SOC storage increased considerably by 8% under CM and 20% under CB, while remained unchanged under CS, compared to CK. The total methane (CH4) and nitrous oxide (N2O) emissions were considerably increased by 7 folds and 15% under CS and 3.5 folds and 61% under CM, respectively, compared to CK. In contrast, these emissions considerably decreased under CB by 33% for CH4 and 29% for N2O. Consequently, the C emission efficiency considerably reduced under CS and CM but increased under CB over the two rotation cycles monitored. Moreover, the soil quality index (SQI) considerably improved under CM and CB but remained unchanged under CS compared to CK. Among the different forms of straw return, manure, and biochar, straw amendments differed considerably in their effects on C sequestration, GHG emissions, and crop productivity. Only biochar from crop residues synergistically improved these functions in the short‐term following application to paddy soil.

422. MANAGEMENT OF ANASTOMOTIC LEAK AFTER TOTAL GASTRECTOMY WITH THE “RENDEZ-VOUS” HYBRID TECHNIQUE: PRESENTATION OF OUR APPROACH AND RESULTS

Abstract Background Anastomotic dehiscence following total gastrectomy and Roux-en-Y reconstruction remains a demanding clinical scenario, associated with high morbidity and mortality rates. Management options focus on controlling systemic and local sepsis while allowing for proper anastomotic healing. Optimal treatment algorithm remains to be determined and therapeutic strategy is being individualized. The primary goal of the present study is to present the modified rendezvous stenting technique, a technique implemented in our department during reoperation for washout, in critically ill anastomotic leak patients. Methods We performed a retrospective descriptive analysis of severely ill patients suffering an anastomotic leak from an esophagojejunal anastomosis, who had been operated in our department during the last five years (01/2018-12/2023). All patients were operated on by the same surgical team and endoscopy was performed by the same endoscopist. Data regarding patients who had been subjected to the modified rendezvous technique were collected. Results Since 2018, five anastomotic leak patients underwent stenting over the anastomosis using the modified rendezvous technique during relaparotomy. Stenting was effective in controlling local contamination in 4 out of 5 patients (80%). One patient required repeat stent placement due to stent migration. Overall the 30 day mortality rate was 20% and no deaths directly attributed to the leak were observed. Stents remained in position for an average of 4.25 weeks. Conclusion Anastomotic stenting using the rendezvous technique is a safe and feasible technique. It can prove useful in controlling local abdominal contamination in severe anastomotic leak patients, while minimizing the risk of stent migration. Further implementation of the technique will allow for more reliable conclusions to be drawn, regarding the technique’s actual effectiveness.

Scale-dependent population drivers inform avian management in a declining saline lake ecosystem.

Shrinking saline lakes provide irreplaceable habitat for waterbird species globally. Disentangling the effects of wetland habitat loss from other drivers of waterbird population dynamics is critical for protecting these species in the face of unprecedented changes to saline lake ecosystems, ideally through decision-making frameworks that identify effective management options and their potential outcomes. Here, we develop a framework to assess the effects of hypothesized population drivers and identify potential future outcomes of plausible management scenarios on a saline lake-reliant waterbird species. We use 36 years of monitoring data to quantify the effects of environmental conditions on the population size of a regionally important breeding colony of American white pelicans (Pelecanus erythrorhynchos) at Great Salt Lake, Utah, US, then forecast colony abundance under various management scenarios. We found that low lake levels, which allow terrestrial predators access to the colony, are probable drivers of recent colony declines. Without local management efforts, we predicted colony abundance could likely decline approximately 37.3% by 2040, although recent colony observations suggest population declines may be more extreme than predicted. Results from our population projection scenarios suggested that proactive approaches to preventing predator colony access and reversing saline lake declines are crucial for the persistence of the Great Salt Lake pelican colony. Increasing wetland habitat and preventing predator access to the colony together provided the most effective protection, increasing abundance 145.4% above projections where no management actions are taken, according to our population projection scenarios. Given the importance of water levels to the persistence of island-nesting colonial species, proactive approaches to reversing saline lake declines could likely benefit pelicans as well as other avian species reliant on these unique ecosystems.

592P Survival analysis of surgical management options for goblet cell adenocarcinoma: Insights from machine learning clustering

592P Survival analysis of surgical management options for goblet cell adenocarcinoma: Insights from machine learning clustering