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Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.
Abdominal adhesions are the foremost complication following abdominal surgery, yet there is a noticeable lack of effective laboratory assessments that can be integrated with adhesion scoring systems to predict and quantify these adhesions. This study aims to explore the relationship between plasma fibrinogen (Fg) and abdominal adhesions, and to assess the feasibility of incorporating plasma Fg into a simplified Peritoneal Adhesion Index (PAI) score to predict and quantify these adhesions. This retrospective study analyzed clinical data from 231 patients diagnosed with acute appendicitis who underwent surgery at The Third People's Hospital of Xinjiang Uygur Autonomous Region from July 2022 to August 2024. A comprehensive dataset including basic demographic information and laboratory results was compiled. Preoperative variables such as course of disease, plasma Fg, d-dimer, white blood cell count, neutrophil count, monocyte count, eosinophil count, basophil count, and lymphocyte countwere considered as independent variables. In the logistic regression analysis, the status of abdominal adhesion served as the dependent variable; in contrast, the simplified PAI score was the dependent variable in the multiple linear regression analysis. A cohort of 63 patients requiring emergency surgical intervention were prospectively enrolled for predictive modeling analysis between July 2022 and August 2024. Logistic regression analysis identified plasma Fg as an independent predictor of abdominal adhesion status, while other parameters showed no significant correlations. The area under the receiver operating characteristic curve (AUC) for diagnosing abdominal adhesion status using Fg was 0.856. The optimal cut-off value was identified as 3.205 g/L, with sensitivity and specificity values of 72.3% and 88.4%, respectively. The multiple linear regression analysis revealed significant associations of both course of disease (β=0.269, p = 0.001) and Fg (β=0.627, p < 0.001) with the simplified PAI score. The predictive equation formulated was: Y (simplified PAI score) = 1.928 + 0.269 * course (days) + 0.672 * Fg (g/L), resulting in an R-squared value of 0.487. The predictive model demonstrated an overall accuracy of 73.06% in identifying abdominal adhesion formation when using the predetermined cutoff value. Regarding the equation-based prediction of preoperative abdominal adhesions, the model showed limited predictive capability in adhesion-free patients, with an accuracy of merely 8.57%. However, in patients with abdominal adhesions, the predictive performance was as follows: precise prediction was achieved in 11 cases (39.28%), predictions with 1-point deviation were observed in 12 cases (42.86%), while deviations of 2 and 3 points were noted in 3 and 2 cases, respectively. By defining a Fg level below 3.205 g/L as indicative of no adhesions and applying the predictive equation only to patients with Fg levels of 3.205 g/L or higher, the overall predictive accuracy of the simplified PAI score significantly improved to 82.53% . Plasma Fg significantly correlates with abdominal adhesion and serves as a reliable predictor of abdominal adhesion status in patients undergoing acute abdominal surgery prior to intervention. The simplified PAI score correlates with both Fg and course of disease. However, used in isolation, the predictive equation shows suboptimal performance, particularly exhibiting reduced accuracy in patients without adhesions. To enhance predictive accuracy, it is advisable to integrate the criterion of Fg levels below 3.205 g/L as indicative of the absence of adhesions into the predictive equation for assessing abdominal adhesions.
Left ventricular thrombus caused by acute catecholamine cardiomyopathy combined with pheochromocytoma crisis (PC) is extremely rare in clinical practice, and there are no reports of patients with median arcuate ligament syndrome (MALS) at the same time. This report describes the case of a 45-year-old woman admitted to the cardiology department with this rare condition. The patient presented with severe abdominal pain, vomiting, rapid blood pressure (BP) fluctuations, and recurrent hypotensive syncope. We discuss the patient's diagnosis and treatment and share our experience with this patient. A combination of PC and MALS has not been previously reported. This successful treatment provides a reference for the future treatment of similar patients, filling a related gap. The treatment methods and outcomes are the most important aspects of patient care. The patient was admitted to the hospital because of chest tightness, headache, abdominal pain, and several episodes of syncope for 4 days. Clinical symptoms, combined with enhanced chest-abdominal computed tomography, 24-hour ambulatory BP monitoring, left and right coronary angiography, and renin-angiotensin-aldosterone and adrenocorticotropic hormone-cortisol measurements, led to a diagnosis of catecholamine cardiomyopathy, PC, and MALS. Continuous invasive arterial and venous BP monitoring, norepinephrine was administered via an intravenous pump, and intravenous crystalloid infusions were administered to improve the patient's significant BP fluctuations. Subsequently, after a gradual improvement in BP fluctuations, an alpha receptor blocker (phenoxybenzamine) was administered orally, and the dose was gradually increased to the target dose to control BP. Finally, after 6 months of optimized medical treatment, the right adrenal tumor was safely resected with complete recovery of cardiac structure and function. During the 6-month follow-up, after the operation, the patient's BP was stable without medication, hypotensive syncope, recurrence of abdominal pain, and tumor recurrence. Key laboratory test results, such as cardiac Troponin I, N-terminal pro-B-type natriuretic peptide, white blood cell, adrenocorticotropic hormone, cortisol, etc, returned to normal levels. First, it highlights the effectiveness of norepinephrine in treating BP fluctuations and hypotensive syncope in patients with pheochromocytoma. Second, we propose a potential pathological interaction between pheochromocytoma and MALS, thereby avoiding surgical treatment of MALS. Third, it confirmed the safety of delayed surgery in patients with high-risk cardiac conditions.
Informed consent represents a cornerstone of ethical and legal surgical practice across numerous healthcare systems, including that of the United Kingdom. Despite its recognised importance, achieving consistency and comprehensiveness in the consent process remains a persistent challenge, particularly within busy and time-constrained clinical environments. This study critically evaluates existing consenting practices in the Department of Trauma and Orthopaedics at Worcestershire Acute Hospitals. It also presents the department's experience with implementing electronic consent (e-consent) forms as a replacement for traditional handwritten documentation. A two-phase study was conducted at a single National Health Service (NHS) trust. In the first phase, 102 handwritten surgical consent forms were retrospectively audited against national guidelines to assess compliance in areas such as timing of consent, legibility, provision of information, and documentation of risks and alternatives. The second phase involved a structured survey of clinicians within the orthopaedic department to explore their experiences with the current process and their perceptions of electronic alternatives. The audit revealed major shortcomings in the handwritten consent process: only 21 % of forms were completed well in advance of surgery, fewer than half provided adequate procedural information, and just 17 % documented all available treatment options. Over 60 % were poorly legible, and most lacked complete documentation of risks and benefits. Survey results indicated widespread clinician dissatisfaction and a strong preference for e-consent systems to improve legibility, clarity, and patient engagement. The study highlights significant deficiencies in handwritten consent practices and supports adopting standardised e-consent systems to enhance communication, patient comprehension, and medico-legal protection.
Artificial intelligence (AI) offers transformative potential for clinical care, yet its deployment in conflict-affected, low-resource settings remains under-researched. This study evaluates AI awareness, barriers, and readiness among Sudanese surgeons amidst the nation's ongoing armed conflict. A sequential explanatory mixed-methods design was employed. An online survey, adapted from validated instruments, assessed AI familiarity, perceived barriers, ethical concerns, and readiness among Sudanese general surgery residents and specialists. From October 2024 to June 2025, 185 completed responses were obtained from a stratified random sample of 195 eligible participants. Follow-up semi-structured interviews were conducted with 20 selected specialists. Quantitative data were analyzed using descriptive statistics, chi-square tests, and the Kruskal-Wallis test with Dunn's post-hoc comparisons. Qualitative interviews were conducted until thematic saturation was achieved and analyzed thematically, with coding verified through inter-coder reliability. While AI awareness was moderate (68.7%), practical clinical exposure (9.4%) and advanced literacy (10.3%) were notably low. Surgeons identified AI's primary utility in training (68.2%) and perioperative decision-making (65.4%). Significant barriers included infrastructure deficits (87.6%), training gaps (79.1%), and financial constraints (72.4%). Conflict-specific challenges were acute, with 92.5% reporting severe technology shortages and 78.3% citing unreliable power/internet. Qualitative themes highlighted AI's potential for triage and resource allocation, though concerns regarding accountability and ethical governance persisted. This study provides inaugural evidence on AI feasibility within an African zone. Despite infrastructure collapse, Sudanese surgeons show strong interest in AI for triage and diagnostics. To move forward, development must prioritize offline-compatible, context-adapted tools and robust governance frameworks. These findings provide a blueprint for integrating AI to bolster surgical resilience during humanitarian crises.
Charcot neuropathic osteoarthropathy complicates an estimated 0.1-7.5% of diabetic patients in general clinic populations, yet misdiagnosis rates remain high - partly because the foot is often warm, swollen, and painless rather than obviously deformed. Undiagnosed cases range from 0.4% to 13% in published series. To detect preclinical Charcot disease by plain X-ray in longstanding diabetic patients attending routine follow-up, before clinical deformity develops. Cross-sectional prevalence/screening study, with structured short-term follow-up restricted to X-ray-positive patients, of 60 consecutive adults with type 2 diabetes mellitus (DM) of >10 years duration, seen at Al-Ramadi Teaching Hospitals between September 2023 and March 2024. All underwent bilateral foot X-ray in antero-posterior and oblique views, full clinical and neurological assessment, and laboratory investigations including HbA1c. Thirty-one patients (51.7%) had X-ray changes fulfilling a pre-specified Charcot pattern - predominantly focal bone demineralization, subchondral fragmentation, and debris formation at articular margins. X-ray positivity correlated significantly with older age (p = 0.024), longer DM duration (p < 0.001), higher HbA1c (p < 0.001), and greater BMI (p < 0.001). Gender and medication type were not significant. At 6-month follow-up, six of the 31 initially positive cases (19.4%) showed radiological progression; all underwent MRI and were offloaded with total contact cast or airwalker. These findings were not adjudicated against MRI or a validated staging system in most cases and represent radiographic suspicion rather than confirmed neuroarthropathy. Over half of longstanding diabetic patients attending routine follow-up had X-ray changes fulfilling a Charcot pattern, though most were not MRI-confirmed. These findings support further investigation, with MRI-validated confirmation in a larger sample, before systematic plain bilateral foot X-ray screening can be recommended in this population; glycemic optimization and patient education on trauma avoidance remain appropriate in the meantime.
Female, woman and/or girl athletes' sport participation rates are rising and associated with high injury rates and burden. Using best-practice consensus methodology, we developed recommendations to guide injury prevention for female/woman/girl athletes. The Female/woman/girl Athlete Injury pRevention (FAIR) International Olympic Committee Consensus meeting was held from 31 March to 2 April 2025 (Lausanne, Switzerland).The FAIR Consensus followed an eight-step hybrid method. 109 authors from six continents conducted: (1) systematic reviews synthesising evidence on injury prevention strategies and modifiable risk factors for lower-extremity and upper-extremity injuries, concussions and spine/chest/abdominal/pelvic injuries/pain, (2) a scoping review synthesising dissemination and implementation (D&I) approaches; and (3) a concept mapping project generating knowledge on gender/sex-related factors for injury prevention. These projects underpinned draft recommendations subsequently voted on by a steering committee (n=24) and an external advisory committee chair over two anonymous survey rounds. Recommendations, Round 1 voting results and suggestions/dissenting comments were discussed between Round 1 and 2 voting. Consensus was defined as 'critical to include' (≥70% scored recommendation as 7-9 (9-point Likert scale, 1=not important; 9=critically important) AND ≤15% scored recommendation as 1-3).The 56 FAIR recommendations address: primary injury prevention (n=16) (policy/rules/laws=6; personal protective equipment=8; training=2); secondary injury prevention (n=4); modifiable risk factors (n=12); approaches to D&I (n=14); and promoting gender/sex-supportive environments (n=10).The FAIR Consensus informs evidence-based best practices and policy for injury prevention, approaches to implementation and creation of supportive environments for female/woman/girl athletes. Every person at all levels of sport can, and should, take responsibility for actions that positively influence female/woman/girl athlete health and safety.
The financial burden, morbidity, and mortality of surgical site infection (SSI) is a global issue. Incidence rates of SSI are high in low- and middle-income countries (LMICs), with evidence of surge in antimicrobial resistance (AMR) in these regions. This mini review aimed to collect and analyze existing data on SSI incidence and the associated AMR in LMICs to address some concerns about causes and control strategies. MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL were all searched for this study until June 8, 2025. We included all studies comparing disparities in surgical site infections and related antimicrobial resistance in low- and middle-income countries. The overall SSI incidence in LMICs is higher than in high-income countries . The intertwined relationship between SSI and the rising AMR burden further complicates the issue. The emergence of AMR is driven by inappropriate antibiotic use, poor regulatory oversight and stewardship, inadequate healthcare infrastructure, economic limitations that result in incomplete or informal treatments, weak surveillance systems, and environmental contamination from hospitals, agriculture, and wastewater. Vaccination, sanitation and hygiene, infection control, education, alternative therapies consideration of, antimicrobial stewardship, and prevention, are strategies to prevent and reduce the development of AMR. AMR is a dire global problem that requires immediate action to combat its spread. Effective AMR surveillance from a "One Health" viewpoint is needed in LMICs to map and track the spread of resistance. Environmental resistome sample is required to detect the factors influencing resistance. Searching for solution to colistin resistance, a last resort antibiotic, is critical.
With the advances of artificial intelligence (AI) in the medical field, particularly the widespread utilization of large language models (LLMs) such as ChatGPT, Claude, Gemini, Llama, and Deepseek, clinical practice is undergoing an unprecedented technological revolution. These cutting-edge technologies facilitate efficient processing and analysis of vast datasets, providing medical professionals with auxiliary diagnoses and treatment suggestions, while markedly enhancing the quality and efficiency of medical services. Over the past decade, the field of thoracic surgery has achieved transformative progress, primarily driven by AI innovations. Consequently, thoracic surgeons must possess a foundational understanding of AI in order to grasp its implications on their daily practice and explore potential ways of integrating this technology into their work. This article reviews the fundamental elements of AI and the relationships between AI-based techniques. It further summarizes the application of AI in thoracic surgery, aiming to enhance thoracic surgeons' comprehensive understanding of the latest developments in this area. Additionally, this article explores the challenges and limitations faced by AI, including data security and privacy concerns, issues of bias and discrimination, challenges in verification and interpretability, ethical and legal considerations, technical obstacles, as well as training and educational requirements. Finally, it explores emerging AI architectures and their paradigm-shifting impacts on medical ecosystems.
Informed consent is a cornerstone of ethical surgical practice, yet significant challenges persist in ensuring patients' comprehension, particularly in low-resource settings. Cultural norms, literacy barriers, and limited institutional support often hinder truly informed decision-making. A hospital-based cross-sectional study was conducted from September to December 2024 at a rural surgical center in Omdurman, Sudan. A total of 422 adult patients undergoing elective surgery were interviewed postoperatively using a validated, culturally adapted questionnaire. Descriptive and inferential statistics were applied to assess patient demographics, perceptions of the informed consent process, and associated barriers. The mean age of participants was 42.0 ± 14.3 years, with a near-equal gender distribution. Only 17.1% of patients signed their own surgical consent forms, with 80.6% of these self-signers being male. Among those whose consent was signed by relatives (82.9%), females were overrepresented (56.6%). While 91.5% recognized the importance of informed consent, only 33.6% understood its medico-legal significance. Consent explanations were predominantly delivered by residents or house officers (62.1%), and just 20.1% of patients felt that the discussion influenced their surgical decision. Self-signers were more likely to recall discussion of surgical complications (75.0% vs. 51.4%; p < 0.001), less likely to recall expected benefits (61.1% vs. 78.9%; p = 0.001), and showed no significant difference for consequences if surgery was not performed (80.6% vs. 82.9%; p = 1.0). Overall satisfaction with the consent process was high (87.7%), though this did not correlate with comprehension. Educational status significantly influenced autonomy, with illiterate participants disproportionately less likely to sign their own forms and more likely to cite language barriers and lack of information (p < 0.05). Despite high reported satisfaction, substantial deficiencies exist in patients' comprehension and autonomy in the informed consent process in Sudan. Gender disparities, literacy limitations, and systemic reliance on junior staff compromise the ethical validity of consent. Interventions tailored to cultural and educational contexts-such as provider training, simplified materials, and patient-centered communication-are urgently needed to enhance informed surgical decision-making in low-resource environments.
Primary hyperparathyroidism (PHPT) is a relatively uncommon endocrine disorder in China. As the national referral center for parathyroid diseases, Peking Union Medical College Hospital (PUMCH) has abundant clinical resources to make parathyroidectomy a valuable surgical procedure for resident training. After completing the training program, residents become proficient in diagnosis and perioperative care, and can perform simple cases under the supervision of senior surgeons. PHPT diagnosis and tumor localization were performed by a multidisciplinary team. Residents were enrolled in a surgical training program under the guidance of experienced senior surgeons. Intraoperative recurrent laryngeal nerve monitoring (IONM) and intraoperative parathyroid detector (IOPD) were employed. Upon completing the training, an online questionnaire was administered to residents to collect feedback on their experience. 122 parathyroidectomies were performed, with 60 residents trained. The mean age was 53.2 ± 13.8 years, and 71.3 % (87 cases) were female. The mean tumor size was 20.6 ± 10.9 mm, and the mean operative time was 73.2±28.6 minutes. No iatrogenic intraoperative injuries or major complications occurred. Serum parathyroid hormone (PTH) declined below the upper limit value (ULV) in 109 cases (89.3 %), and serum calcium declined below the ULV in 110 cases (90.2 %). Only 4 cases (3.3 %) exhibited both PTH and calcium levels above the ULV on postoperative day 1. Within 3 months of follow-up, no surgical complication occurred. Among the 55 residents who responded to the questionnaire (91.7 %), all reported satisfaction with the training. Specifically, 89.1 % felt more confident in acting as chief surgeon, and 94.5 % acknowledged the training's helpfulness for their future careers. Regarding essential technologies, 69.1 % emphasized IONM, while 41.8 % highlighted IOPD. The most frequent suggestions for program improvement were to provide more opportunities and further difficulty-stratified training. In a high-volume center, a parathyroidectomy surgical training program proves feasible and beneficial for residents to master surgical treatment of this rare disease.
This study assessed the effectiveness of a modified simulation-based education (SBE) program, originally designed for vascular surgical trainees, adapted for endovascular scrub nurses (ESNs). The goal was to enhance their technical and non-technical skills and explore the program's impact on operating room (OR) teamwork and workflow. A mixed-methods design was used. Eleven experienced ESNs-each with experience from approximately 100 endovascular procedures in the past 2-3 years-participated in role-reversal simulations, practicing peripheral endovascular procedures in the role of the surgeon under the guidance of a supervisor. Quantitative assessments included the Global Rating Scale (GRS) and an Examiner's Checklist for technical skills, while semi-structured interviews provided qualitative insights into non-technical domains such as teamwork, workflow, and job satisfaction. The program significantly improved ESNs' technical skills, with GRS scores increasing from median [IQR] 19.0 [14.0; 24.0] to 43.0 [32.0; 44.0] (p=.004) and Examiner's Checklist scores rising from 49.0 [45.0; 58.0] to 73.0 [65.0; 78.0] (p=.004). Qualitative findings, derived from the themes of learning potential, job satisfaction, culture, feedback, overwhelming, and COVID-19, further demonstrated improvements in non-technical domains, including understanding of procedural sequences, teamwork, workflow, and job satisfaction. Participants reported better anticipation of surgeons' needs and a more collaborative atmosphere in the operating room. The role-reversal simulation-based education program for ESNs improved technical skills and strengthened teamwork and collaboration in the operating room. These findings highlight the potential of role-reversal training to enhance surgical performance and job satisfaction among OR staff.
Medical innovations have extended patient lifespans while also increasing the clinical complexity associated with aging and chronic conditions. As patients live longer, surgeons may encounter an array of perioperative challenges including patients with multiple comorbidities. Consequently, surgical teams must manage bleeding risks while balancing potential thromboembolic complications. This retrospective observational study evaluated trends in perioperative bleeding management and associated surgical care challenges over 22 years, utilizing data from the Premier Perspective Hospital Database. The analysis included 13,358,404 adult surgical patients, examining patient complexity via Charlson Comorbidity Index (CCI), preoperative anticoagulant/antiplatelet usage, and topical hemostatic agent (THA) utilization. Patient complexity, as indicated by CCI, significantly increased annually across all surgical types, with the greatest increase in cardiovascular surgery (0.029/year). Overall preoperative use of anticoagulants and antiplatelets rose by 0.5 % per year, with marked variations across surgical cohorts. Notably, general surgery exhibited the highest annual increase (2.0 %), while knee and hip replacements showed a decline in anticoagulant/antiplatelet use. Overall, use of THA strategies increased by 0.56 % annually, particularly in neurosurgery, spinal, and cardiovascular procedures. Multivariate analysis demonstrated significant associations between patient complexity, anticoagulant/antiplatelet use, and higher use of THA strategies across various surgical disciplines. Elective surgeries were more likely to be associated with THA charges than emergent or urgent procedures. This large retrospective analysis describes evolving patient complexity, antithrombotic medication use, and associated use of THA strategies across surgical specialties over two decades. These findings characterize practice patterns and may inform future hypothesis-driven studies evaluating the clinical role of THAs in different surgical contexts.
Primary spontaneous pneumothorax (PSP) is the accumulation of air in the pleural space without underlying lung disease. Standard management often involves chest tube insertion connected to an underwater seal drainage system (bottle), but alternatives like the Heimlich one-way valve exist. This study aimed to compare the clinical outcomes of using a Heimlich valve versus standard chest tube drainage for PSP. This was a single-center, open-label, parallel-group randomized controlled trial conducted at Shahid Madani Hospital, Karaj, Iran, from March 2023 to March 2024. Forty patients aged 18-40 years with symptomatic PSP (>15% collapse) were randomized (1:1 ratio) using block randomization. The intervention group received a 28 Fr chest tube connected to a Heimlich valve. The control group received a 28 Fr chest tube attached to an underwater sealed bottle. Primary outcomes included length of hospital stay, time to return to normal activities other outcomes included pain scores (Visual Analog Scale - VAS), dyspnea score (0-10), ease of getting out of bed (0-10), need for ketorolac analgesia, treatment failure (requiring VATS within 7 days), 30-day rehospitalization, and complications. Forty patients (mean age 31.1±7.0 years; 80% male) were randomized to separate groups (20 per group). Baseline characteristics were similar between groups. The mean time to return to normal activities was significantly shorter in the Heimlich group (7.1±5.4 days vs. 10.2±8.0 days, P=0.014). Mean length of hospital stay was 5.6±3.0 days (Heimlich) vs. 7.3±4.6 days (Bottle), (P=0.081). Pain scores were significantly lower in the Heimlich group on days 1-4 (P<0.01). Ketorolac use (frequency and total dose) was significantly lower in the Heimlich group (P<0.001). Ease of getting out of bed was significantly greater in the Heimlich group throughout the assessment period. Pneumothorax resolution trended faster in the Heimlich group (P=0.077 on day 4). Dyspnea trended lower in the Heimlich group on day 4 (P=0.078). Treatment failure (requiring VATS) occurred in 1 (5%) of the Heimlich patients versus 3 (15%) of the Bottle patients (P = 0.29). Rehospitalization occurred in one patient per group (5%, P = 1.00). In patients with PSP, management with a Heimlich valve resulted in a significantly faster return to normal activities, lower pain scores, reduced analgesic requirements, and greater ease of mobilization than standard chest tube drainage. While not statistically significant, trends suggested faster pneumothorax resolution and potentially shorter hospital stays. The Heimlich valve appears to be a safe and effective alternative, offering potential patient comfort and recovery benefits. Iranian Registry of Clinical Trials (IRCT): IRCT20230208057359N1.
The extent to which bowel preparation mechanical (MBP) or oral antibiotic (OA) or in combination (MBP/OA)) should be performed prior to elective colorectal surgery is the subject of ongoing debate. The aim of our study was to investigate the effect of MPB/OA [with single-shot intravenous antibiotic administration before incision (MPB/OA+ivAB)] on the microbiome of patients with colorectal carcinoma (CRC) operated minimally-invasive. We were studying 16 consecutive patients who underwent elective resection surgery for CRC at our centre in a prospective panel study. MBP was performed and 1 g parmomomycin/500 mg metronidazole was administered orally one day preoperatively; 1 g ertapenem was administered intravenously 30 min prior incision. Three mucosal samples were taken preoperatively during colonoscopy and intraoperatively and analysed by 16S rRNA V1-V2 gene sequencing. Before MPB/OA+ivOA, the genera Phocaeicola (10 %), Bacteroides (7 %) and unclassified Ruminococcaceae (6 %) were predominant. After preparation, all bacteria were reduced except Enterococcus (7 %) and Escherichia/Shigella (6 %), which had increased. Significant reductions were seen for Bacteroides (p = 0.01), Haemophilus (p = 0.047), Holdemanella (p = 0.004), Neisseria (p = 0.004), Odoribacter (p = 0.027), unclassified Clostridiales (p = 0.008) and unclassified Ruminococcacaeae (p = 0.009). Large effect sizes (Cohens'd) were seen for Bacteroidetes (d = 0.864) and unclassified Ruminococcacaeae (d = 0.909). In our pilot study, we observed a significant reduction in seven bacterial genera after MBP/OA+ivAB in patients with CRC. Some of these bacterial genera have been associated with anastomotic insufficiency. Further, large in-depth analyses are needed to evaluate perioperative microbial drift with postoperative complications.
Honduras has the highest rates of teen pregnancy and HIV in Central America, which are disproportionately concentrated in rural, low-income communities with high school dropout rates and limited access to sexual health education. This study evaluated the 'Taking Care of You' (TCY) program, a community-based educational intervention designed to improve reproductive health knowledge and social risk awareness among adolescents aged 11-18 years in rural northwest Honduras. We conducted a single-group, pre-post quasi-experimental study in El Rosario, Locomapa, Honduras. Eighty-seven adolescents were recruited through community leaders and school networks and participated in eight 3-h sessions from April to July 2024, covering sexual and reproductive health and social risk behaviours. A structured questionnaire with quantitative and qualitative components was administered pre- and post-intervention. McNemar tests, Wilcoxon signed-rank tests, and logistic regression models were used for quantitative analysis; descriptive-interpretive thematic analysis was applied to qualitative data. Before TCY, only 35.6% of participants knew about sexually transmitted infections (STIs), and fewer than half recognised risks of unprotected sex or substance use. Following TCY, there was increased knowledge on STIs, recognition of unprotected sex risks, self-assessed reproductive health knowledge, attitudes toward contraception, and comfort discussing sexual health and behaviours. Equitable gains were made across sex and age groups. Qualitative findings revealed shifts from stigma and avoidance toward openness and protective intentions. Knowledge and attitudinal gains were observed across sex and age groups; however, sustained behavioural change will require longer follow-up and continued structural support. Controlled trials with extended follow-up are needed to assess long-term behavioural impact.
Red blood cell (RBC) transfusion in cardiac surgery is associated with adverse outcomes and increased costs. Traditional predictors such as hemoglobin and BMI offer limited physiologic insight. This study evaluates RBC mass, a calculated measure of total red cell volume, as a preoperative predictor of transfusion in adult cardiac surgery patients undergoing cardiopulmonary bypass (CPB). This retrospective observational study included 463 adult patients undergoing elective cardiac surgery with CPB at a single academic center in 2024. Exclusion criteria included procedures with inherently high transfusion risk (e.g., redo sternotomy, LVAD implantation, circulatory arrest, and "bring-backs"). RBC mass was calculated using estimated blood volume (sex-adjusted mL/kg) and hematocrit. Patients were categorized into three RBC mass groups: 1-2 L, 2-3 L, and >3 L. Multivariable logistic regression was used to assess the association between RBC mass and transfusion, adjusting for sex, age, BMI, and bypass time. Of the 463 patients, 102 (22 %) received RBC transfusions. Transfused patients had significantly lower RBC mass (mean 1.95 L) versus non-transfused (2.58 L, p < 0.001). Patients in the 1-2 L group accounted for 54.9 % of transfusions despite representing only 25.5 % of the cohort. These patients had 18.7 times the odds of transfusion compared to those with >3 L RBC mass. Female sex, older age, lower BMI, and longer CPB time were also associated with increased transfusion risk. RBC mass proved a more physiologically integrated and predictive metric for transfusion risk than hemoglobin or BMI alone. It may be especially useful in identifying at-risk female patients and those with normal hemoglobin but limited oxygen-carrying reserve. Preoperative RBC mass is a strong independent predictor of transfusion in cardiac surgery. Its incorporation into preoperative planning may improve patient optimization and reduce unnecessary transfusions.
This study aimed to investigate the tumor microenvironment (TME) of metastatic PDAC, focusing on tumor-infiltrating leukocytes (TILs) and metabolic checkpoint molecules (MCMs). The role of TME in primary and metastatic PDAC is not well understood. Furthermore, the role of energy metabolism in metastatic PDAC is unclear. Therefore, this study aimed to explore the TME in primary tumors and metastases of PDAC, and its prognostic role. We included 26 cases of metastatic PDAC in this study. We performed immunohistochemistry for TILs and MCMs (HIF-1α, GLUT1, and PDHK1) in primary and corresponding metastatic tumor tissues. We quantified stromal TILs and MCMs using a tumor immune stroma (QTiS) algorithm and correlated the data with clinical outcome. We found that CD3+, CD8+, and CD20+ TILs were increased in primary tumors compared to metastatic ones. Kaplan-Meier plots revealed that high infiltration of CD20+ and its combinations in primary tumors correlated with better OS in metastatic PDAC patients. We also found that high infiltration of CD8+ TILs in metastatic tumors correlated with better OS, as did the low density of GLUT1 in both PDAC primary and metastatic tumors. A multivariate Cox regression analysis revealed that CD8+ TILs in metastatic tumors and GLUT1 in PDAC primary and metastatic tumors were independent predictors of survival. Distribution of TILs in the TMEs of primary and metastases of metastatic PDAC is different. Our results suggest that TILs (CD8+) and MCMs (GLUT1) in tumor stromal areas can predict OS of patients with metastatic PDAC.
The aim of this study was to compare the influence of two different methods of distal screw insertion during intramedullary nailing of humeral shaft fractures on radiation exposure and operative time. A single-center retrospective study, which included 44 patients, was conducted. Patients were divided into the Freehand and Calibration groups according to the technique used for distal screw insertion. Medical records were used to collect baseline characteristics of patients and complications, and operative reports were used to collect data for outcomes which included number of expositions, dose area product (DAP), fluoroscopy time and operation time. Operation time was defined as time from skin incision to final suture. There were no significant differences noted between the groups in gender, age, fracture side and fracture type distribution. The mean DAP in the Calibration group measured 232.8 ± 130.1 μGy·m2, and was lower than in the Freehand group where measured value was 305.4 ± 141.6 μGy·m2, without significant difference between the groups (p = 0.084). Mean fluoroscopy time was also lower in the Calibration group of patients (32.3 ± 12.7 s) than in the Freehand group (39.4 ± 14.6 s), with p = 0.094. Mean operative time was shorter in the Calibration group (68.8 ± 27.1 min) in comparison with the Freehand group (76.5 ± 17.7 min), but without statistically significant difference (p = 0.272). The usage of calibration technique for distal locking screw insertion has similar operative time and intraoperative radiation exposure during intramedullary nailing of humeral shaft fractures compared with the freehand technique.
Severe alcohol-associated hepatitis (sAH) is a leading indication for liver transplant (LT). However, access to LT begins with referral, a step that may not have been previously characterized using prospective multicenter data with detailed measures of social determinants of health. To examine the association of clinical severity and neighborhood disadvantage with referral, wait-listing, transplant, and short-term mortality in patients hospitalized with sAH. This prospective multicenter cohort study was a secondary analysis of the Alcohol-Associated Hepatitis Network observational cohort. It included patients hospitalized with sAH (Model for End-Stage Liver Disease [MELD] >20) across 5 US transplant centers from May 6, 2019, to November 8, 2023. Clinical, demographic, and social determinants of health data, including the Area Deprivation Index (ADI), were collected prospectively. Clinical severity (MELD score) and neighborhood-level disadvantage (ADI). The primary outcomes were referral for LT evaluation, wait-listing, and receipt of LT, and the secondary outcome was 180-day mortality. Logistic regression and generalized additive models were used to evaluate independent and interactive associations of MELD and ADI with outcomes. The cohort included 325 patients (mean [SD] age, 44.8 [10.2] years; 197 males [60.6%]). The mean (SD) MELD score was 29.2 (7.6), and the mean (SD) ADI was 56.2 (24.4). Only 120 patients (36.9%) were referred for LT. In multivariable analysis, higher MELD scores were associated with lower referral odds (odds ratio, 1.13 [95% CI, 1.07-1.18]; P < .001). ADI was not associated with referral odds (odds ratio, 0.99 [95% CI, 0.97-1.00]; P = .06). Generalized additive model analyses demonstrated significant MELD × ADI interactions for referral (P for interaction = .01), wait-listing (P for interaction = .004), and mortality (P for interaction = .01). At a MELD score 20 to 30, referral probability was 40% to 60% among patients with an ADI less than 30 vs 20% among those with an ADI 30 or more. Among patients with a MELD score 20 to 30, mortality exceeded 20% in those with an ADI 60 or more compared with 10% to 20% in those with an ADI less than 20. In this multicenter cohort study of severe alcohol-associated hepatitis, neighborhood disadvantage was associated with referral at intermediate MELD scores. These findings suggest that referral is a critical leverage point for interventions and that outreach and navigation strategies informed by social context may improve access to LT.