搜索结果：come

Adhesions are a common complication following surgery, and they can cause significant morbidity. However, adhesions are not easily diagnosed with imaging, and often only become apparent when they cause intestinal obstruction symptoms. The pathophysiology of adhesion formation is complex, thus despite advances in surgical techniques and postoperative care, adhesions remain a persistent problem in clinical practice. Despite evidence for efficacy of some strategies in reducing adhesion formation question remain regarding the indications and impact on clinically relevant outcomes. The paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a thorough examination of the pathophysiological mechanisms underlying adhesion formation and assess the efficacy of existing preventive strategies to guide future research and clinical practice in the management of adhesions. Study design and Framework This position paper was developed in accordance with the World Society of Emergency Surgery (WSES) methodology for consensus-based guidelines. The objective was to synthesize current evidence on adhesion pathophysiology and translate it into a clinically applicable "Narrative". Expert Panel Selection and Composition: The expert panel was composed of international specialists in general, trauma, and emergency surgery. Experts were selected based on their clinical leadership and academic contributions to the fields of peritoneal surgery and postoperative complication management. The panel included senior representatives from major surgical departments in Singapore (Sengkang and Singapore General Hospital), The Netherlands (Radboud University), and Italy (University of Bologna and Bufalini Hospital). Literature Search and Evidence Synthesis: A comprehensive search was conducted across major medical databases (e.g., PubMed, Scopus, Cochrane Library) to identify literature concerning the pathophysiology and prevention of adhesions. The search strategy employed Medical Subject Headings (MeSH) descriptors and keywords including: "peritoneal adhesions," "postoperative adhesions," "adhesion prevention," "adhesion barriers," "carboxymethylcellulose," "hyaluronic acid," "icodextrin," "oxidized regenerated cellulose," "polyethylene glycol," "adhesive small bowel obstruction," "adhesiolysis". No language restrictions were applied to the search strategy. A total of 56 studies were selected, including systematic reviews, meta-analyses, randomized clinical trials (RCTs), and retrospective cohort studies. The panel focused on clinically relevant outcomes, specifically looking for evidence that connected interventions to reduced rates of adhesive small bowel obstruction (ASBO) and reoperation. Studies were screened based on their ability to address three specific pillars: surgical approach (MIS vs. Open), technical manoeuvres (haemostasis and tissue handling), and the use of mechanical or chemical adjuncts. Consensus Achievement and Formulation: The recommendations were developed through a structured, iterative revision process: Literature Synthesis: Lead authors performed the primary review and drafted the pathophysiological and preventative sections. Internal Peer Review: The manuscript underwent rigorous revision by the international expert panel to reach a consensus on the position statements. Final Validation: All authors reviewed and approved the final manuscript and the resulting "Bundle" recommendations to ensure they were supported by the cited data. A total of 56 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been included in this paper to be discussed. Surgical techniques, as well as chemical and mechanical barriers were discussed in depth in this paper to come up with the recommendation. The WSES expert panel suggests the following bundle to reduce postoperative peritoneal adhesions: Bundle 1: Whenever possible, opt for minimally invasive surgery (MIS) or laparoscopic procedures. Bundle 2: Good surgical techniques. Bundle 3: Utilise barriers.

Poor operating room (OR) ergonomics pose risk of injury to OR staff, worsening patient outcomes and threatening workforce wellness and sustainability. How OR staff navigate ergonomic barriers in the interdisciplinary team environment was examined in this qualitative study. Semi-structured, open-ended interviews of surgeons, anaesthesiologists and OR nurses were conducted at single institution using a socio-material approach with interview-to-the-double. Transcripts were coded by two independent researchers. Themes in the data were outlined using the System Engineering Initiative for Patient Safety (SEIPS) framework. Five major themes were identified. First, physical environment issues creating cognitive and physical frictions, such as tripping hazards and improper room layouts. Second, influence of social positionality, with hierarchy by role and experience and social dynamics leading to differential capacity to adjust. Third, team collaboration, with lack of interdisciplinary work and communication and high staff turnover. Fourth, burden of self-initiated work arounds, outlining conflict between system/organizational issues but individual solutions. Fifth, institutional support, with lack of leadership engagement. Participants suggested solutions including accommodations to foster a collaborative approach to managing discomfort in the OR, and new team communication tools. Ergonomic barriers were described within the work system of the SEIPS framework. Social positionality and differential levels of agency, as well as lack of team collaboration and misperceptions of others' roles, were central to ergonomic challenges. Conflicts between problems lying with the system/organization, but solution being left to individuals, were also central to challenges to optimal OR ergonomics. Operating rooms are tough places to work. Staff spend long hours in cramped spaces, holding awkward positions around heavy equipment and tangled cables. Most develop pain or injuries. Up to 100% of surgeons and 98% of anaesthesiologists report muscle or joint problems. When staff are in pain or distracted by hazards, the risk of mistakes during surgery goes up. To understand how surgeons, nurses, and anaesthesiologists deal with physical strain at work and what gets in the way of making the operating room safer. Twenty-four staff members were interviewed for this qualitative study at a large hospital in Toronto, Canada (10 anaesthesiologists, nine surgeons, and five nurses). They were asked to describe a typical day in detail. Two researchers reviewed the interviews and identified common themes. Five main issues were found. First, rooms are cluttered with unneeded equipment, and cables on the floor are constant tripping hazards. Second, there is a clear pecking order. Surgeons’ needs tend to come first. Nurses often wait for surgeons to suggest a break, even when in pain. Junior staff across all roles push through discomfort rather than speak up, because doing so carries real risk. Third, teamwork helps but is inconsistent. When people talk about physical needs, solutions emerge, but these conversations rarely happen. Fourth, staff are left to solve problems alone by creating personal fixes for issues that come from the hospital system, not from individuals. Fifth, staff feel unsupported by leadership, who they believe care more about efficiency and financial targets than worker safety. Worker safety in the operating room depends on how the team works together, who has the power to speak up, and whether the hospital takes responsibility. Right now, most solutions fall on individuals even though the problems come from the system. Hospitals need to invest in better equipment, stable teams, and a culture where everyone feels safe to speak up.

Cardiovascular disease (CVD) remains the leading cause of death worldwide. While advances in treatment have improved outcomes, the greatest gains in public health will come from primary prevention. Risk stratification is the foundation of CVD prevention. Traditional tools, such as pooled cohort equations (PCEs) and SCORE2, do not capture non-traditional risk factors and individual variability, driving efforts to refine existing approaches. We critically discuss emerging risk determinants for primary CVD prevention. Coronary artery calcium scoring can reclassify CVD risk but has limitations related to cost, access, and unvalidated improvements in clinical endpoints. Biomarkers such as apolipoprotein B and lipoprotein(a) may identify residual risk beyond LDL-C, particularly in patients with lipid discordance, but remain underused due to uncertain thresholds and the lack of prospective triallevel outcome data. Trials of colchicine in primary prevention have yielded mixed results, making the role of targeting inflammation unclear in CVD prevention. Polygenic risk scores can stratify genetic risk but face challenges in sensitivity, specificity, and generalizability. Multiomics approaches, while offering the promise of deeper phenotyping, lack established clinical applications and consensus on when their use is appropriate. Artificial intelligence may allow better prediction across cohorts but requires broader validation. Clonal hematopoiesis of indeterminate potential, a marker of inflammation and age-related CVD risk, lacks evidence supporting routine screening or intervention in younger, asymptomatic individuals. The proliferation of new risk stratification tools poses a key challenge: determining when additional data meaningfully alter clinical decisions. Until robust outcome-based evidence emerges, risk enhancers should guide, but not dictate, therapy in selected patients.

Most results for stereotactic radiotherapy (SRT) for acromegaly patients come from Gamma-Knife series. We aim to describe outcomes for LINAC-based SRT, as well as compare results for single-dose (SRS) and fractionated (SFRT) treatments. Single-center retrospective cohort in a tertiary, academic hospital assessed between 2008 and 2024. A total of 48 patients were assessed for outcomes of acromegaly after SRT. Most of them female (62.5%). Mean age was 42.5 years (range 12-73). Median lesion size was 2.1 cm (range 0.2 to 7.2 cm). Among previous deficits, previous hormonal deficits (31.3%) and visual deficits (45.8%) were common. Most patients were diagnosed with pure somatotrophic lesions (87.5%). SRS was done in 16 (33.3%) patients and 32 (66.7%) underwent SFRT. Concurrent octreotide long-acting release (Oct-LAR) (29/60.4%) and cabergoline (20/41.7%) were also common. Median follow-up was 85.3 months (8.2-187.9 months). Tumor control was achieved in 47 (97.9%). Mean progression-free survival (PFS) was 85.3 months (92.4 months for SRS and 81.7 months for SFRT, p  = 0.42). Univariate analysis showed no variable impacted overall survival (OS), PFS, new visual, or new hormonal disorders. Hormonal remission was achieved in 22 (45.8%) patients. Median time to hormonal disease control (THC) was 73.1 months for the entire cohort, and 45.8 months for SRS patients and 74.7 months for SFRT patients, with no difference between groups ([HR], 0.30; 95% CI, -1.14 to 0.53; p  = 0.47). We described acromegaly patients treated with LINAC SRS and with the current criteria for hormonal cure. THC was longer for SFRT patients, with no statistical differences. Concurrent treatment did not impact outcomes.

Registries have long been a cornerstone of medical research and public health, providing systematically collected data on diseases, treatments, and health outcomes. However, in the era of digital health, we argue that the traditional model of stand-alone registries needs reconsideration, given the context of increasingly digitized and interoperable health data ecosystems. Unless registries evolve to embrace embedded, standards-based data services, operating across interoperable infrastructure, they will become obsolete while digitalization is reshaping how data can be collected, shared, and used. In this viewpoint, we recount how the present health data ecosystem came to be and what role registries have come to play therein. Following that, we show how recent regulatory initiatives such as the Trusted Exchange Framework and Common Agreement in the United States or the European Health Data Space Regulation signal a shift toward cross-network health information exchange, promoting patient-centric data integration within electronic health record systems. We further illustrate how electronic health records are consequently set to evolve into information hubs, acting as the primary gateway for individuals through which they may access and control their personal health data spread throughout increasingly connected health data ecosystems. This, in turn, might stimulate the creation of digital twins and continuous learning health systems in practice. Following this line of thought, we discuss the opportunities and challenges of interconnected health data ecosystems. Ultimately, we propose that next-generation registries need to be designed as dynamic, service-oriented software stacks for research, leveraging the common data infrastructures that are currently being established around the world. Given the points raised in this viewpoint, we invite health care professionals and researchers alike to equally rethink the role that registries should play within the globally emerging interconnected health data ecosystems and contribute their findings. References included in this viewpoint were identified through searches of PubMed and Google Scholar with various search terms and combinations thereof pertinent to the topics touched on, for example, "patient registry," "clinical registry," "digital twin," "healthcare," "clinical research," "virtual twin," "TEFCA," or "EHDS." Only papers in English were reviewed. The final reference list was generated on the basis of originality and relevance to the broad scope of topics covered in this viewpoint, aiming to present a balanced overview of topic-related findings and arguments.

Postoperative pancreatic fistula (POPF) remains one of the most dreaded complications after pancreatoduodenectomy (PD), especially in patients with soft pancreatic parenchyma and a small main pancreatic duct. In this context, total pancreatectomy (TP) has been proposed to prevent the occurrence of POPF, although its metabolic consequences limit its widespread adoption. To compare the postoperative outcomes of PD and TP in patients at high risk of POPF, assessing morbidity, mortality, and metabolic consequences. A systematic literature search was conducted according to the PRISMA recommendations, including comparative studies of PD versus TP in a high-risk population. The criteria analyzed included morbidity, mortality, oncological outcomes and the occurrence of insulin-dependent diabetes mellites. The available data suggest a reduction in overall morbidity and severe complications after TP, but at the cost of a high rate of postoperative diabetes mellites. Islet cell auto-transplantation (IAT) could mitigate these metabolic consequences, and has shown encouraging results on glycemia control and the preservation of residual insulin secretion. In patients at high risk of POPF, TP may be a pertinent alternative to PD, especially in complex anatomical or oncological situations. However, the metabolic benefit-risk balance needs to be carefully assessed, and strategies such as TP-IAT may improve functional outcomes. Additional randomized controlled trials are needed, including an accurate assessment of postoperative quality of life.

Tocilizumab (TCZ), an interleukin-6 receptor inhibitor, is effective for moderate to severe rheumatoid arthritis (RA). However, maintaining remission after TCZ withdrawal remains challenging, and the treatment duration required before discontinuation to minimize relapse risk is unclear. To identify a TCZ treatment-duration threshold before withdrawal that is associated with a lower risk of relapse in patients with RA. This was a retrospective study including 97 patients with RA who discontinued intravenous TCZ after stable disease control. We retrospectively analyzed 97 RA patients who achieved remission or low disease activity prior to TCZ withdrawal. The primary outcome was relapse within 12&#x2009;months post-discontinuation. Cox proportional hazards regression identified independent predictors, while restricted cubic spline (RCS) modeling assessed non-linear associations between treatment duration and relapse risk. A simplified risk stratification tool was developed and internally validated using bootstrap resampling. Among 97 patients with RA who discontinued TCZ after stable disease control, most were biologic-na&#xef;ve (98.9%), the mean disease duration was 72.9&#x2009;&#xb1;&#x2009;52.7&#x2009;months, and concomitant methotrexate and hydroxychloroquine were used in 73.2% and 47.4% of patients, respectively. During the 12-month follow-up, 54 patients (55.7%) relapsed. TCZ treatment duration was an independent protective factor (adjusted HR&#x2009;=&#x2009;0.892&#x2009;per month, p&#x2009;=&#x2009;0.002), whereas anti-citrullinated protein antibody (ACPA) positivity was associated with increased relapse risk (adjusted HR&#x2009;=&#x2009;2.122, p&#x2009;=&#x2009;0.031). RCS analysis demonstrated an L-shaped non-linear relationship, identifying an empirically derived duration threshold at approximately 200&#x2009;days associated with lower relapse risk. A simplified score assigning 1 point each for ACPA positivity and TCZ duration&#x2009;<&#x2009;200&#x2009;days stratified patients into low- (0 points), intermediate- (1 point), and high-risk (2 points) groups, with relapse rates of 27.3%, 53.8%, and 91.7%, respectively; the model showed acceptable discrimination (AUC&#x2009;=&#x2009;0.76). Longer TCZ treatment duration and ACPA negativity were associated with a lower risk of relapse after TCZ withdrawal. An approximately 200-day treatment duration may serve as a clinically informative threshold for risk-stratified withdrawal decisions in routine practice, although disease control after withdrawal should be interpreted in the context of ongoing background therapy rather than confirmed drug-free remission. How long should tocilizumab be used before stopping in rheumatoid arthritis? Rheumatoid arthritis is a long-term condition in which the immune system attacks the joints, causing pain, swelling, and damage. Tocilizumab is a medicine that can control the disease well, but doctors and patients often face an important question: when can it be safely stopped? In this study, we reviewed 97 patients with rheumatoid arthritis whose disease was well controlled before they stopped tocilizumab. We then followed them for 12 months to see who remained stable and who had a return of symptoms. We found that a little more than half of the patients had a relapse within 1 year after stopping treatment. Two factors were especially important. First, patients who stayed on tocilizumab for a longer time were less likely to relapse. Second, patients who had a positive anti-citrullinated protein antibody blood test were more likely to relapse. Our analysis suggested that about 200 days of treatment may be an important time point. Patients who stopped treatment before this were much more likely to have their disease come back. We also developed a simple tool based on treatment duration and antibody status that could separate patients into low-, medium-, and high-risk groups. These results suggest that stopping tocilizumab too early may increase the chance of relapse, especially in patients with a positive antibody test. This may help doctors and patients make more informed decisions about treatment withdrawal. However, because this was a single-center retrospective study, larger studies are needed to confirm these findings.

Hawking radiation1-the emission of quantum particles at the event horizon of a black hole2-connects gravity with quantum mechanics and thermodynamics3-5. But Hawking radiation has never been observed in astronomy, only in laboratory analogues6-9, and the chances of ever observing it in space are astronomically small9. The energy of Hawking radiation must come from the gravitational field around the black hole2, but how field quanta generate Hawking quanta has been unknown. Here we report on experimental and theoretical evidence for the process that generates Hawking radiation in a fibre-optical analogue of the event horizon10,11. There, as in gravity2, it has been believed that Hawking radiation comes from a complicated, cascaded process12; here we have identified theoretically a simple, direct process and observed experimentally how this process reacts back onto the field. Our findings suggest an equally direct process for other laboratory analogues6-8,13-17 and perhaps also for gravitational fields, shedding light on how black holes might radiate.

Antimicrobial resistance (AMR) is a major global health threat, largely driven by inappropriate and excessive antibiotic use. Italy has historically reported antibiotic consumption rates above the European average, especially in primary care. In 2017, Italy implemented the National Action Plan on Antimicrobial Resistance (NAP-AMR), including targets for reducing overall community antibiotic and fluoroquinolone use. This study evaluated the impact of NAP-AMR on antibiotic consumption trends in Italian primary care from 1999 to 2024. Quasi-experimental interrupted time series study. Annual ECDC data were expressed as defined daily doses (DDD) per 1000 inhabitants per day. Total antibiotic consumption was analyzed for 1999-2024 and fluoroquinolone consumption for 2005-2024. Segmented linear regression with Newey-West standard errors estimated post-2017 changes in level and trend. Total systemic antibiotic consumption was the primary outcome, and fluoroquinolone consumption was the secondary outcome. Total antibiotic consumption showed a significant pre-intervention upward trend, increasing annually by 0.10 DDD per 1000 inhabitants per day (annual change&#xa0;=&#xa0;0.096; p&#xa0;=&#xa0;0.032; 95% CI: 0.014 to 0.178). NAP-AMR implementation was associated with a significant immediate reduction in total antibiotic use (mean level difference&#xa0;=&#xa0;-4.940; p&#xa0;=&#xa0;0.003; 95% CI: -7.864 to -2.016), while the post-intervention slope change was not significant (annual change&#xa0;=&#xa0;0.126; p&#xa0;=&#xa0;0.606; 95% CI: -0.346 to 0.599). Fluoroquinolone consumption showed a significant pre-intervention upward trend (annual change&#xa0;=&#xa0;0.039; p&#xa0;=&#xa0;0.016; 95% CI: 0.011 to 0.066) and a significant immediate reduction (mean level difference&#xa0;=&#xa0;-1.079; p&#xa0;=&#xa0;0.023; 95% CI: -1.910 to -0.248). The post-intervention trend was negative but not significant (annual change&#xa0;=&#xa0;-0.219; p&#xa0;=&#xa0;0.096; 95% CI: -0.459 to 0.021). NAP-AMR was associated with immediate reductions in total antibiotic and fluoroquinolone consumption, but sustained trend changes were not statistically significant. No significant long-term trend change was observed, underscoring ongoing surveillance and future evaluation.

Adolescence is an important developmental period during which there are diverse changes in the brain and behavior. Goal-directed behaviors and the component processes underlying those behaviors improve during adolescence, including working memory, response inhibition, and reinforcement learning. At the same time there is substantial pruning of excitatory connections in prefrontal cortex and ongoing myelination of axons. However, psychiatric disorders also become increasingly prevalent in late adolescence and early adulthood. In this study, we develop computational models that suggest a hypothesis for how the ongoing changes in the brain can give rise to the increased prevalence of psychiatric disorders. We show that both myelination and pruning during adolescence lead to attractor landscapes in which strongly encoded memories, driven by three-factor learning rules that modulate Hebbian plasticity, come to dominate the landscape of brain activity, at the expense of weakly encoded memories. Pruning and myelination lead to large, strong attractors which, if they are related to aversive emotions, can drive intrusive thoughts and compulsions in obsessive compulsive disorder, rumination in depression, and aversive memories in post-traumatic stress disorder. The link between pruning, myelination and the emergence of dominant attractors for emotionally salient memories is well supported by the models. The way these effects map onto forebrain circuits requires more work.

The concept of at-homeness has been increasingly adopted in residential care to describe a metaphorical sense of being "at home". Within a sector often criticised for displacing residents from familiar environments, at-homeness has come to symbolise the ideal experiential outcome of care. Yet, despite a growing body of work enriching our understanding of what at-homeness entails, existing conceptualisations tend to overlook the processes through which at-homeness is personally and multiply constructed and are shaped predominantly by studies of older adults in long-term care contexts. To address these limitations, a qualitative study, employing a user-involved approach, was conducted in Hong Kong, incorporating in-depth interviews with 60 residents of mental health residential services and ethnographic observations across three hostels. Analysis shows that at-homeness is shaped through boundary-setting and bonding between the self and three arenas-social relations ("people"), material environments and temporal orientations. Residents interpreted core qualities of at-homeness across personal, relational, material and temporal dimensions and their constructions were guided by distinct logics involving self-appraisal, temporal integration, relational attunement and socio-cultural grounding. The study proposes an integrative framework that reframes at-homeness as a dynamic, negotiated process, offering new insights for advancing theory and strengthening methodological and practice approaches in residential care.

The human gastrointestinal (GI) microbiota has come to be recognized as a modulator of health. However, interest in fungi and their function as members of the microbiota has lagged behind interest in bacteria. Despite the lack of historical interest, fungi are prevalent in the human GI tract and have an outsized impact on host immunity. In this review, we aim to examine the associations and potential impact of yeasts on human health outcomes. This review summarizes the associations between yeasts and inflammatory bowel diseases, highlights the predictive service that yeasts may provide in cancer therapy, and explores the possibility of yeasts as therapeutic effectors. There remain significant challenges in data analysis and identifying the relevance of fungal morphology; however, the pathways for clinical translation open to yeasts in the GI tract make these challenges worth overcoming.