Morbidity Complications Research Articles

Inguinal Lymphadenectomy for Penile Cancer: An Interim Report from a Trial Comparing Open Versus Videoendoscopic Surgery Using a Within-patient Design

Background and objectiveNodal metastasis is a major survival and prognostic factor in penile cancer (PeCa). Thus, accurate staging, prognosis, and treatment selection require adequate inguinal lymphadenectomy (ILND). ILND surgery should balance oncologic rigor with morbidity and postoperative complications. Our aim was to compare the feasibility and safety of open ILND (OILND) and videoendoscopic ILND (VEILND) in patients with PeCa. MethodsWe conducted a single-center randomized trial with a within-patient design between October 2019 and April 2023. Patients who were undergoing either staging or radical ILND for PeCa were included and randomized to receive either OILND or VEILND on one side, with the other technique then used on the contralateral side. The trial was approved by the local ethics committee and was registered on ClinicalTrials.gov (NCT05887921). The primary outcome was the safety of VEILND. Secondary outcomes included intraoperative and postoperative morbidity rates and surgical outcomes for the two procedures, as well as oncological outcomes according to survival estimates. Key findings and limitationsWe included 14 patients in the study. Median follow-up was 12 mo (interquartile range [IQR] 12–17). There were no significant differences in operative time and the number of lymph nodes removed between OILND and VEILND. However, the median time to drain removal was significantly shorter in the VEILND group (15 d, IQR 13–17, 95% confidence interval [CI] 12–17) than in the OILND group (27 d, IQR 20–41, 95% CI 24–31; p = 0.025). No intraoperative complications were observed, but postoperative complications occurred in three cases (21.4%, 95% CI 8.4–37.8%) in the VEILND group and eight (57.1%, 95% CI 18.6–54.3%) in the OILND group (p = 0.032). Conclusions and clinical implicationsVEILND represents a safe technique to consider for either staging or curative intent in PeCa and seems to have an advantage over OILND in terms of morbidity. Further high-powered studies are warranted to confirm these preliminary results. Patient summaryWe compared the outcomes of two different surgical techniques to remove lymph nodes in patients with penile cancer. We found that a video-assisted keyhole surgery approach seems to result in a lower rate of complications than after open surgery.

Nursing care in patients with cesarean section due to premature rupture of membranes in the obstetrics and gynecology service, Lima hospital

Premature rupture of membranes (RPM) is defined as the loss of continuity of the amniotic membranes with leakage of transvaginal amniotic fluid, which occurs before the onset of labor, where cesarean section is medical-surgical treatment with the purpose of avoid complications of neonatal maternal morbidity and mortality. The objective of the study was to manage the nursing care process for a patient with cesarean section by RPM. The nursing care process had a qualitative approach, single case type, of methodology, which included a 35-year-old woman, in which the five stages of the PAE were applied where the assessment was carried out applying the assessment guide of the patterns. of Maryori Gordon, three nursing diagnoses were prioritized: acute pain, risk of infection and anxiety, using the NANDA-I taxonomy. In the planning and execution stage, the care plan was prepared considering the Taxonomy NOC, NIC and in the last evaluation stage a change score +2, +2, +2 was obtained. It is concluded that the application of the PAE allows to provide specialized care in a comprehensive and quality manner throughout the recovery process

Enhanced recovery after surgery (ERAS) novel protocol for management of esophageal replacement in children: A single surgeon's experience of 116 cases

BackgroundPerioperative management of esophageal replacement is challenging due to significant disturbance in internal milieu of the body. To mitigate mediastinal dissection induced systemic inflammatory response, there is an unmet need to design and test a goal directed, resource conscious protocol for enhanced recovery, which will serve as a template to reduce morbid surgical complications and length of hospital stay. MethodsA retrospective cohort study was designed by convenience sampling method to group patients to compare outcomes of pediatric esophageal replacement using conventional protocol vs enhanced recovery after surgery novel protocol. Primary outcome measure was post-operative total length of stay in hospital. Secondary outcome measures were frequency of cardio-pulmonary complications, anastomotic leaks, infections, mortality, and initiation of early enteral jejunostomy feeding. ResultsA total of 116 children with corrosive esophageal injury [n = 21(19%)] and esophageal atresia [n = 95(81 %)] were analyzed in this study. Novel protocol group(n = 62) when compared to conventional protocol group (n = 54) had lower mean total length of stay days (13.05 ± 7.92 days vs.21.96 ± 6.5 days p < 0.0001), shorter mean ICU days (5.74 ± 4.16 days vs 7.13 ± 3.16 days; p ≤ 0.048) and Novel protocol group had lower cardiac [3/62 (5 %) vs 12/54(22 %) p = 0.012]; and pulmonary [4/62 (6.5 %) vs 13/54(24 %) p = 0.007] complications. Novel protocol group had lower mean days to initiation of enteral feeding (3.13 ± 0.71 vs 5.45 ± 0.75 days; p < 0.0001) and lower rates of post-operative infections [5/62(8 %) vs 18/54 (33 %); p = 0.001]. ConclusionsEnhanced recovery after surgery novel protocol has the potential to change clinical practice due to mitigation of major complications.

Improving Diabetic Wound-Healing Outcomes With Topical Growth Factor Therapies.

Diabetes mellitus is associated with morbid complications such as diabetic foot ulcers (DFUs) that may lead to amputations or mortality if not managed adequately. New adjunctive interventions to treat diabetic wounds include topical biologics and growth factors. This study aims to evaluate their efficacy in improving wound-healing outcomes and safety. Comprehensive database searches of MEDLINE via PubMed, EMBASE, and Cochrane were performed from inception to December 2022. Three independent researchers selected the studies. Randomized controlled trials that compared the use of a topical biologic growth factor-containing regimen to other biologics or standard of care (SOC) were included. This review followed PRISMA guidelines. Risk of bias analysis was performed using the Jadad scale. Network meta-analysis was performed. Treatments were grouped into common nodes based on the type of biologic agent. Primary outcomes of interest were healing rate and time to wound closure. Secondary outcomes included wound infection, serious adverse events (AEs), and amputation rate. Human umbilical cord (HUC) was associated with the highest cure, followed by recombinant human epidermal growth factor (hEGF). A significantly greater reduction in the time to cure DFUs was seen in HUC, hEGF, and fibroblast growth factor (FGF). There was a significantly lower risk of AEs when platelet-rich plasma (PRP) was administered. HUC, hEGF, and FGF are promising topical biologics with statistically significant primary outcomes compared to SOC, while PRP is effective in reducing ulcer-related AEs. HUC has been found to be the most effective in terms of cure rate and a reduction in time to cure.

Microwave Ablation of the Pig Growth Plate: Proof of Concept for Minimally Invasive Epiphysiodesis.

Different surgical methods for epiphysiodesis of limb length discrepancy (LLD) have been described. Although these methods are variably effective, they are associated with morbidity (pain and limp) and potential complications. Microwave ablation is a less-invasive opportunity to halt growth by selectively destroying the growth plate via thermal energy to treat LLD in children. In this proof-of-concept study using an in vivo pig model, we asked: (1) What is the durability of response 2 to 4 months after microwave ablation of the tibial growth plate as measured by length and angulation of the tibia via a CT scan? (2) Was articular cartilage maintained as measured by standard histologic staining for articular cartilage viability? To develop an in vivo protocol for microwave ablation, we placed microwave antennas adjacent to the proximal tibia growth plate in the cadaveric hindlimbs of 18 3-month-old pigs. To determine the suitable time, we varied ablation from 90 to 270 seconds at 65-W power settings. After sectioning the tibia, we visually assessed for discoloration (implying growth plate destruction) that included the central growth plate but did not encroach into the epiphysis in a manner that could disrupt the articular surface. Using this information, we then performed microwave ablation on three live female pigs (3.5 to 4 months old) to evaluate physiologic changes and durability of response. A postprocedure MRI was performed to ensure the intervention led to spatial growth plate alterations similar to that seen in cadavers. This was followed by serial CT, which was used to assess the potential effect on local bone and growth until the animals were euthanized 2 to 4 months after the procedure. We analyzed LLD, angular deformity, and bony deformity using CT scans of both tibias. The visibility of articular cartilage was compared with that of the contralateral tibia via standard histologic staining, and growth rates of the proximal tibial growth plate were compared via fluorochrome labeling. Eighteen cadaveric specimens showed ablation zones across the growth plate without visual damage to the articular surface. The three live pigs did not exhibit changes in gait or require notable pain medication after the procedure. Each animal demonstrated growth plate destruction, expected limb shortening (0.8, 1.2, and 1.5 cm), and bony cavitation around the growth plate. Slight valgus bone angulation (4º, 5º, and 12º) compared with the control tibia was noted. No qualitatively observable articular cartilage damage was encountered from the histologic comparison with the contralateral tibia for articular cartilage thickness and cellular morphology. A microwave antenna placed into a pig's proximal tibia growth plate can slow the growth of the tibia without apparent pain and alteration of gait and function. Further investigation and refinement of our animal model is ongoing and includes shorter ablation times and comparison of dynamic ablation (moving the antennae during the ablation) as well as static ablation of the tibia from a medial and lateral portal. These refinements and planned comparison with standard mechanical growth arrest in our pig model may lead to a similar approach to ablate growth plates in children with LLD.

Pathogens Causing Pediatric Community Acquired Urinary Tract Infections and Their Increasing Antimicrobial Resistance: A Nationwide Study.

Urinary tract infections (UTIs) in childhood are common and are associated with considerable acute morbidity and long-term complications. The need for updated data to optimize empiric antibiotic therapy is crucial. We aimed to investigate the pathogens causing pediatric community acquired UTIs, their correlation with demographic characteristics, and trends in their antimicrobial resistance. This nationwide cross-sectional study included all 53,203 children (<18 years) diagnosed with UTI in community outpatient clinics in the following selected years: 2007, 2011, 2015, 2019 and 2021. Escherichia coli (E. coli) (82.1%) was the most common uropathogen, followed by Enterobacter, Klebsiella, Proteus, Pseudomonas, and Enterococcus species. The bacterial distribution displayed statistically significant (p < 0.0001) gender- and sector-specific patterns with a higher relative prevalence of non-E. coli UTI in Jewish and males. The rate of extended-spectrum beta-lactamase-positive E. coli increased substantially and significantly (p < 0.001) from only 6.1% in 2007 to 25.4% in 2021. Most non-E. coli uropathogens exhibited resistance to commonly used empiric antibiotics for UTIs in children. These findings are significant in guiding optimal empiric antibiotic treatment for pediatric community acquired UTIs. The resistance of uropathogens to antimicrobials is region- and time-dependent. Therefore, the periodic and local assessment of antibiotic resistance trends is essential to update guidelines and provide the most appropriate antibacterial therapy for children with UTIs.

Utility of Platelet Indices as Prognostic Markers of Sepsis: A Medical Intensive Care Unit-Based Cross-Sectional Study at a Rural Setup.

Introduction Even after the breakthrough advancements in the management and prognostic scoring of sepsis, it remains an important cause of morbidity and mortality encountered in intensive care units (ICUs) throughout the globe. This study highlights the utility of platelet indices as prognostic markers of sepsis. Methods In the present prospective cross-sectional study, a total of 177 patients with sepsis were enrolled using the Sepsis-3 criteria. The platelet indices were then linked to severity using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. The correlation of platelet indices to morbidity in terms of the length of ICU stay, need for a mechanical ventilator, types of infection, and mortality was also assessed. Results The results showed that mean platelet volume (p = 0.004) and platelet distribution width (PDW; p = 0.009) were positively correlated with the severity of sepsis. Among all the parameters, plateletcrit (%) was the best predictor of the need for an invasive mechanical ventilator at a cutoff point of ≤0.22 with a 60.90% chance of correctly predicting the need for an invasive mechanical ventilator, as was mortality at a cutoff point of ≤0.22 with a 67.30% chance of correct prediction. Among the platelet indices, only PDW showed a significant association with growth in culture because patients with growth had significantly higher PDW as compared to those who did not have growth (22.4 ± 4.47 vs 20.81 ± 4.29, p = 0.011). Conclusion The difference between the survivors and non-survivor groups was statistically significant for platelet indices, making them easily available, cost-effective, and useful prognostic markers for patients in septic shock. This will help in easy understanding and preventing its morbid complications, even at the primary care physician level.

Abdominal Wall Tension and Early Outcomes after Posterior Component Separation with Transversus Abdominis Release: Does a "Tension-Free" Closure Really Matter?

Ventral hernias result in fibrosis of the lateral abdominal wall muscles, increasing tension on fascial closure. Little is known about the effect of abdominal wall tension on outcomes after abdominal wall reconstruction. We aimed to identify an association between abdominal wall tension and early postoperative outcomes in patients who underwent posterior component separation (PCS) with transversus abdominis release (TAR). Using a proprietary, sterilizable tensiometer, the tension needed to bring the anterior fascial elements to the midline of the abdominal wall during PCS with TAR was recorded. Tensiometer measurements, in pounds (lb), were calibrated by accounting for the acceleration of Earth's gravity. Baseline fascial tension, change in fascial tension, and fascial tension at closure were evaluated with respect to 30-day outcomes, including wound morbidity, hospital readmission, reoperation, ileus, bleeding, and pulmonary complications. A total of 100 patients underwent bilateral abdominal wall tensiometry, for a total of 200 measurements (left and right side for each patient). Mean baseline anterior fascial tension was 6.78 lb (SD 4.55) on each side. At abdominal closure, the mean anterior fascial tension was 3.12 (SD 3.21) lb on each side. Baseline fascial tension and fascial tension after PCS with TAR at abdominal closure were not associated with surgical site infection, surgical site occurrence, readmission, ileus, and bleeding requiring transfusion. The event rates for all other complications were too infrequent for statistical analysis. Baseline and residual fascial tension of the anterior abdominal wall do not correlate with early postoperative morbidity in patients undergoing PCS with TAR. Further work is needed to determine if abdominal wall tension in this context is associated with long-term outcomes, such as hernia recurrence.

Clinical and economic impact of the introduction of pre-biopsy MRI-based assessment on a large prostate cancer centre diagnostic population and activity: 10years on.

Prostate mpMRI was introduced in 2011 as a secondary test and subsequently integrated into a prostate cancer (PCa) diagnostics unit representing a population of approximately 550,000 people. The following represents an audit of its step-wise introduction between 2 index years, 2009 and 2018, focusing on the activity, patient outcomes and economic benefits. PATIENTSAND METHODS: The 2 distinct years were selected for relying on a transrectal ultrasound biopsy pathway in 2009 to an mpMRI-based pathway in 2018. All referrals were retrospectively screened and compared for age, PSA levels, DRE findings, biopsy history, biopsy and mpMRI allocation data. Cost analysis was determined using local unit procedure costs. Patients referred included 648 in 2009 and 714 in 2018. mpMRI seldomly informed decision to biopsy in 2009 (9.8%), while in 2018 it was performed in the pre-biopsy setting in 87.9% cases and enabled biopsy avoidance in 137 patients. In 2018, there was a 31.8% decrease in the number of biopsies in patients without previous PCa diagnosis, coupled with an increase in diagnostic rates of csPCa, from 28.6 to 49.0% (p < 0.0001) and a reduction in negative biopsy rates from 52.3 to 33.8%. mpMRI had a positive impact on the system with reduced patient morbidity and post-procedural complications. The estimated overall cost savings amount to approximately £75,000/year for PCa diagnosis and £11,000/year due to reduced complications. Our evaluation shows the mpMRI-based pathway has improved early detection of csPCa and reduction of repeat biopsies, resulting in significant financial benefits for the local healthcare system.

A156 INCIDENCE OF MALIGNANT GASTRIC OUTLET OBSTRUCTION IN PATIENTS WITH PANCREATIC CANCER UNDERGOING FOLFIRINOX THERAPY

Abstract Background Malignant gastric outlet obstruction is a morbid complication of pancreatic cancer. There is currently a lack of epidemiology data characterizing its incidence and outcomes in patients with unresectable pancreatic head cancer undergoing chemotherapy with leucovorin, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX). Determining the incidence of MGOO in this context is crucial for developing effective management strategies. Aims We aim to ascertain the incidence of MGOO in patients with pancreatic cancer treated with FOLFIRINOX. Secondary objectives include evaluating the clinical outcomes of MGOO. The primary endpoint was the rate of malignant gastric outlet obstruction, defined as clinical evidence of MGOO confirmed with axial imaging and/or endoscopy. Secondary endpoints included the length of hospitalization for MGOO and the rate of successful endoscopic or surgical management. Methods This was a retrospective, single-center study including patients with pancreatic head cancer treated with FOLFIRINOX between January 1, 2017, and December 31, 2022, who did not undergo surgical resection. Patients were excluded if they had pancreatic cancer located in the neck, body, and/or tail of the pancreas, had predominantly cystic cancer, had an oncological resection, had a prophylactic surgical gastrojejunostomy, or had metastatic cancer to the pancreas. Results Overall, 44 patients with pancreatic head cancer (40.90% female, mean age 59.3 ± 8.5 years) were included. There was no statistically significant difference in tumor staging between MGOO and No-MGOO patients: overall, 6.8% borderline, 40.9% metastatic, and 52.3% locally advanced. The incidence of MGOO in patients with pancreatic head cancer was 36.36%. Patients who never developed MGOO experienced significantly shorter unplanned hospitalizations (mean ± SD: 20.8 ± 18.30 days) compared to those with MGOO (mean ± SD: 50.33 ± 41.22 days; p = 0.0175). The mean number of FOLFIRINOX cycles received was 7.2 (±5.43) for patients without MGOO and 8.1 (±5.81) for patients with MGOO (p = 0.6152). Among patients with MGOO (n=12), management strategies included EUS-guided gastrojejunostomy (43.75%), duodenal stent placement (31.25%), and medical management (25%). Conclusions Our contemporary data suggest a high rate of MGOO (36%) in patients with advanced pancreatic head cancer undergoing FOLFIRINOX treatment. The development of MGOO was associated with longer total hospitalization when compared to patients who never developed MGOO. Our study underscores the significant negative impact of MGOO with further research needed to elucidate better management strategies including better endoscopic or surgical prophylactic measures. Funding Agencies CIHR

Prevalence and determinants of adverse perinatal outcomes of preeclampsia with severe features at two selected public hospitals in Addis Ababa, Ethiopia.

Preeclampsia is a new onset of hypertension and either proteinuria or end-organ failure after 20 weeks of gestation. It is a prevalent cause of perinatal mortality, morbidity, and neonatal complications in developing nations including Ethiopia. Thus, the aimed to assess the prevalence and determinants of adverse perinatal outcomes among women with preeclampsia with severity features (PEWSF) at two selected public hospitals in Addis Ababa, Ethiopia, 2023. A cross-sectional study was carried out among 348 mothers between January 1, 2023, and July 1, 2023. A structured, pre-tested questionnaire was used to gather data from in-person interviews and a review of the patient's medical record. The statistical program Epi-Data version 4.6 was used to enter the data, and SPSS version 26.0 was used for analysis. Binary logistic regression analysis was used to find factors that were associated with unfavorable perinatal outcomes. A p-value of less than 0.05 was used to declare the significance level. The overall prevalence of unfavorable perinatal outcomes was 59.2% (95% CI: 54.0-63.8). Among the complications, low birth weight, prematurity, NICU admission, and a low fifth-minute APGAR score, encompass 48.9%, 39.4%, 20.4%, and 14.7%, respectively. No formal education [OR = 5.14, 95% CI: (1.93-13.63)], unemployment [OR = 0.42, 95% CI: (0.24-0.73)], referral cases [OR = 2.03, 95% CI: (1.08-4.06), inadequate antenatal care (ANC) contact [OR = 3.63, 95% CI: (1.22-10.71)], and family history of hypertension [OR = 1.99, 95% CI: (1.03-3.85)] have shown a statistically significant association with unfavorable perinatal outcomes. In this study, the prevalence of unfavorable perinatal outcomes was high compared to other studies in Ethiopia. Level of education, occupation, mode of admission, ANC contact, and family history of hypertension were significant predictors of unfavorable perinatal outcomes. Socio-economic development, improving referral systems, and adequate antenatal care contact are needed to improve unfavorable outcomes. Additionally, antenatal screening and specialized care for high-risk mothers, e.g., those with a family history of hypertension are recommended.

Mesenchymal stem cell-derived exosomes: a promising alternative in the therapy of preeclampsia.

Preeclampsia (PE) is a common morbid complication during pregnancy, affecting 2%-8% of pregnancies globally and posing serous risks to the health of both mother and fetus. Currently, the only effective treatment for PE is timely termination of pregnancy, which comes with increased perinatal risks. However, there is no effective way to delay pathological progress and improve maternal and fetal outcomes. In light of this, it is of great significance to seek effective therapeutic strategies for PE. Exosomes which are nanoparticles carrying bioactive substances such as proteins, lipids, and nucleic acids, have emerged as a novel vehicle for intercellular communication. Mesenchymal stem cell-derived exosomes (MSC-Exos) participate in various important physiological processes, including immune regulation, cell proliferation and migration, and angiogenesis, and have shown promising potential in tissue repair and disease treatment. Recently, MSC-Exos therapy has gained popularity in the treatment of ischaemic diseases, immune dysfunction, inflammatory diseases, and other fields due to their minimal immunogenicity, characteristics similar to donor cells, ease of storage, and low risk of tumor formation. This review elaborates on the potential therapeutic mechanism of MSC-Exos in treating preeclampsia, considering the main pathogenic factors of the condition, including placental vascular dysplasia, immunological disorders, and oxidative stress, based on the biological function of MSC-Exos. Additionally, we discuss in depth the advantages and challenges of MSC-Exos as a novel acellular therapeutic agent in preeclampsia treatment.

A Diagnostic Nomogram Incorporating Prognostic Nutritional Index for Predicting Vaginal Invasion in Stage IB - IIA Cervical Cancer.

With the advancements in cancer prevention and diagnosis, the proportion of newly diagnosed early-stage cervical cancers has increased. Adjuvant therapies based on high-risk postoperative histopathological factors significantly increase the morbidity of treatment complications and seriously affect patients' quality of life. Our study aimed to establish a diagnostic nomogram for vaginal invasion (VI) among early-stage cervical cancer (CC) that can be used to reduce the occurrence of positive or close vaginal surgical margins. We assembled the medical data of early-stage CC patients between January 2013 and December 2021 from the Fujian Cancer Hospital. Data on demographics, laboratory tests, MRI features, physical examination (PE), and pathological outcomes were collected. Univariate and multivariate logistic regression analyses were employed to estimate the diagnostic variables for VI in the training set. Finally, the statistically significant factors were used to construct an integrated nomogram. In this retrospective study, 540 CC patients were randomly divided into training and validation cohorts according to a 7:3 ratio. Multivariate logistic analyses showed that age [odds ratio (OR) = 2.41, 95% confidence interval (CI), 1.29-4.50, P = 0.006], prognostic nutritional index (OR = 0.18, 95% CI, 0.04-0.77, P = 0.021), histological type (OR = 0.28, 95% CI, 0.08-0.94, P = 0.039), and VI based on PE (OR = 3.12, 95% CI, 1.52-6.45, P = 0.002) were independent diagnostic factors of VI. The diagnostic nomogram had a robust ability to predict VI in the training [area under the receiver operating characteristic curve (AUC) = 0.76, 95% CI: 0.70-0.82] and validation (AUC = 0.70, 95% CI: 0.58-0.83) cohorts, and the calibration curves, decision curve analysis, and confusion matrix showed good prediction power. Our diagnostic nomograms could help gynaecologists quantify individual preoperative VI risk, thereby optimizing treatment options, and minimizing the incidence of multimodality treatment-related complications and the economic burden.

P366 Risk factors and outcomes of chronic antibiotic-refractory pouchitis in Korean ulcerative colitis patients: a single center retrospective study

Abstract Background Chronic inflammation of the pouch after total proctocolectomy with ileal pouch-anal anastomosis (IPAA) remains a morbid complication in ulcerative colitis (UC). The goal of this study was to investigate risk factors and clinical outcomes of chronic antibiotic-refractory pouchitis (CARP) in Korean patients with UC. Methods This was a single center retrospective study on patients with UC who underwent total proctocolectomy with IPAA at Asan Medical Center in Korea between January 1987 and December 2022. CARP was defined as failure to respond to a 4-week course of a single antibiotic, needing more than 4 weeks of therapy with 5-aminosalicylates, steroids, immunomodulators or biologics/small molecules, while chronic antibiotic-dependent pouchitis (CADP) was defined as more than 3 episodes of pouchitis per year or persistent symptoms requiring long-term antibiotics to maintain disease remission. Primary outcomes were endoscopic remission defined as complete mucosal healing of chronic pouchitis and pouch failure defined as the requirement of diverting loop ileostomy or pouch excision. Univariable and multivariable logistic regression analysis were used to identify risk factors of CARP. Results A total of 251 patients were included and 232 were analyzed (Male, 57.3%; Current smoker, 13.4%; Median age at surgery, 44 years; Disease duration at surgery, 4 years; Previous exposure to biologics/small molecules, 23.7%; Extra-intestinal manifestations, 8.2%; Preoperative cytomegalovirus infection, 19.4%). The most common cause of surgery was steroid refractoriness (50.9%), followed by dysplasia/colorectal cancer (26.7%). The median time from surgery to chronic pouchitis was 48 months (interquartile range 23.5–100.0). Among 74 patients (31.9%) with chronic pouchitis, 31 patients (13.4%) were CARP and 43 patients (18.5%) were CADP. The most frequent endoscopic phenotype according to Chicago classification was focal inflammation of the pouch in all groups (chronic pouchitis, 47.3%; CARP, 35.5%; CADP, 55.8%). Patients with CARP were less likely to have concomitant probiotics compared with CADP (29.0% vs 72.1%; p&amp;lt;0.01). Endoscopic remission rate in chronic pouchitis, CARP, and CADP were 14.9% (11/74), 9.7% (3/31), and 18.6% (8/43), respectively (Table 1). Pouch failure rate in chronic pouchitis, CARP, and CADP were 13.5% (10/74), 16.1% (5/31), and 11.6% (5/43), respectively (Table 1). In a multivariable analysis, current smoking status was positively associated with CARP development (OR: 3.56; 95% confidence interval 1.33–9.52; p=0.01). Conclusion Current smoker with UC who underwent IPAA had a higher risk of CARP. Concomitant use of probiotics was less likely to be associated with developing CARP.

Metabolic and other morbid complications in congenital generalized lipodystrophy type 4.

Morbidity and mortality rates in patients with autosomal recessive, congenital generalized lipodystrophy type 4 (CGL4), an ultra-rare disorder, remain unclear. We report on 30 females and 16 males from 10 countries with biallelic null variants in CAVIN1 gene (mean age, 12 years; range, 2 months to 41 years). Hypertriglyceridemia was seen in 79% (34/43), hepatic steatosis in 82% (27/33) but diabetes mellitus in only 21% (8/44). Myopathy with elevated serum creatine kinase levels (346-3325 IU/L) affected all of them (38/38). 39% had scoliosis (10/26) and 57% had atlantoaxial instability (8/14). Cardiac arrhythmias were detected in 57% (20/35) and 46% had ventricular tachycardia (16/35). Congenital pyloric stenosis was diagnosed in 39% (18/46), 9 had esophageal dysmotility and 19 had intestinal dysmotility. Four patients suffered from intestinal perforations. Seven patients died at mean age of 17 years (range: 2 months to 39 years). The cause of death in four patients was cardiac arrhythmia and sudden death, while others died of prematurity, gastrointestinal perforation, and infected foot ulcers leading to sepsis. Our study highlights high prevalence of myopathy, metabolic abnormalities, cardiac, and gastrointestinal problems in patients with CGL4. CGL4 patients are at high risk of early death mainly caused by cardiac arrhythmias.

Improving outcomes in emergency general surgery: Construct of a collaborative quality initiative.

Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. We collected data at 10 hospitals from July 2019 to December 2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative versus nonoperative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were White, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% confidence interval [CI], 3.2-3.7), morbidity rate was 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial nonoperative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. Therapeutic/Care Management; Level III.

The enhanced recovery after surgery (ERAS) protocol implementation in a national tertiary-level hospital: a prospective cohort study.

Successful colorectal surgery is determined based on postoperative mortality and morbidity rates, complication rates, and cost-effectiveness. One of the methods to obtain an excellent postoperative outcome is the enhanced recovery after surgery (ERAS) protocol. This study aims to see the effects of implementing an ERAS protocol in colorectal surgery patients. Eighty-four patients who underwent elective colorectal surgery at National Tertiary-level Hospital were included between January 2021 and July 2022. Patients were then placed into ERAS (42) and control groups (42) according to the criteria. The Patients in the ERAS group underwent a customized 18-component ERAS protocol and were assessed for adherence. Postoperatively, both groups were monitored for up to 30 days and assessed for complications and readmission. The authors then analyzed the length of stay and total patient costs in both groups. The length of stay in the ERAS group was shorter than the control group [median (interquartile range) 6 (5-7) vs. 13 (11-19), P<0.001], with a lower total cost of [USD 1875 (1234-3722) vs. USD 3063 (2251-4907), P<0.001]. Patients in the ERAS group had a lower incidence of complications, 10% vs. 21%, and readmission 5% vs. 10%, within 30 days after discharge than patients in the control group; however, the differences were not statistically significant. The adherence to the ERAS protocol within the ERAS group was 97%. Implementing the ERAS protocol in colorectal patients reduces the length of stay and total costs.

360 Degrees Endoscopic Access to and Through the Orbit.

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Multilevel Analysis of The Implementation of The Health Belief Model on Antenatal Visit at Integrated Health Posts in Kapuas Hulu, West Kalimantan, Indonesia

Background: Antenatal care (ANC) is carried out to prevent causes of morbidity (illness or complications) and mortality (death) in pregnant women and children. This study aimed to determine the relationship between the application of the health belief model and the behavior of utilizing/visiting antenatal services. Subjects and Method: The research was conducted with a cross-sectional study design. The approach taken was to use an analytical observational model with a sample size of 213 pregnant women. This research was conducted at the Kapuas Hulu District Health Center. This research was conducted in November-December. A sample of 213 pregnant women was selected using stratified random sampling. The dependent variable in this study is ANC visits. Meanwhile, the independent variables in this study were perceived vulnerability, perceived severity, perceived benefits, self-efficacy, and gestational age. Data collection was carried out using a questionnaire and data was analyzed using a multilevel multiple linear regression analysis model. Results: ANC visits increased with high perceived susceptibility (b= 0.13; 95% CI= 0.06 to 0.20; p &lt; 0.001), high perceived severity (b= 0.17; 95% CI= 0.12 to 0.21; p &lt; 0.001), high perceived benefit ( b=0.13; 95% CI= 0.09 to 0.18; p &lt;0.001), high self-efficacy (b= 0.11; 95% CI= 0.03 to 0.18; p=0.005), and high gestational age (b= 0.15; 95% CI = 0.10 to 0.20; p &lt; 0.001). Conclusion: Several constructs in the Health Belief Models which include perceived vulnerability, perceived severity, perceived benefits and perceived self-efficacy can be used as predictors of antenatal visits for pregnant women at Integrated service post, Kapuas Hulu Regency, West Kalimantan Province. Resulting in an ICC of 14.9%, which means there is a contextual influence of Integrated service post on antenatal visits of pregnant women. Keywords: multilevel analysis, health belief model theory, antenatal care, pregnant women. Correspondence: Titis Cipta Purwantanti. Master’s Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami 36A, Surakarta 57126, Central Java, Indonesia. Email: tantie354@gmail.com. Mobile: +6282159504448.

Vaccination against pertussis in Latin American preterm and low-birth weight infants: experts opinion position for a neglected childhood age group

ABSTRACTBackgroundPertussis remains as one of the oldest leading vaccine-preventable diseases of childhood, despite many decades of primary vaccine doses’ and boosters’ implementation. Although the epidemiology is well understood in infants and children, premature babies and low-birth weight infants remain a special group where the disease incidence is unknown, severity of the disease is considerable, and specific vaccination recommendations are scarce.Research design and methodsA retrospective review of the available evidence of pertussis vaccination in premature and low birth weight infants was analyzed from January 2000 to December 2022 in six selected countries: Argentina, Mexico, Colombia, Panamá, Costa Rica, and Chile.ResultsChile had reports of adverse effects associated with vaccination of premature infants with the pentavalent vaccine, and their rationale to switching to the hexavalent vaccine. Colombia had reports of the justification for the use of hexavalent vaccine in prematures in the Neonatal Units and Kangaroo Mother Programs throughout the country. Mexico had selected publications of the vaccination status in prematures and low-birth weight infants.ConclusionDespite its importance, increased morbidity, and highest risk of complications in premature babies, there is a paucity of information of vaccine recommendations and coverage rates among selected Latin American infants.