Comparison of prognosis and postoperative morbidities between standard pancreaticoduodenectomy and the TRIANGLE technique for resectable pancreatic ductal adenocarcinoma

BACKGROUND Radical surgery combined with systemic chemotherapy offers the possibility of long-term survival or even cure for patients with pancreatic ductal adenocar-cinoma(PDAC),although tumor recurrence,especially locally,still inhibits the treatment efficacy.The TRIANGLE technique was introduced as an extended dissection procedure to improve the R0 resection rate of borderline resectable or locally advanced PDAC.However,there was a lack of studies concerning postoperative complications and long-term outcomes of this procedure on patients with resectable PDAC.PDAC.METHODS Patients with resectable PDAC eligible for PD from our hospital between June 2018 and December 2021 were enrolled in this retrospective cohort study.All the patients were divided into PDstandard and PDTRIANGLE groups according to the surgical procedure.Baseline characteristics,surgical data,and postoperative morbidities were recorded.All of the patients were followed up,and the date and location of tumor recurrence,and death were recorded.The Kaplan-Meier method and log-rank test were used for the survival analysis.RESULTS There were 93 patients included in the study and 37 underwent the TRIANGLE technique.Duration of operation was longer in the PDTRIANGLE group compared with the PDstandard group[440(410-480)min vs 320(265-427)min](P=0.001).Intraoperative blood loss[700(500-1200)mL vs 500(300-800)mL](P=0.009)and blood transfusion[975(0-1250)mL vs 400(0-800)mL](P=0.009)were higher in the PDTRIANGLE group.There was a higher incidence of surgical site infection(43.2%vs 12.5%)(P=0.001)and postoperative diarrhea(54.1%vs 12.5%)(P=0.001)in the PDTRIANGLE group.The rates of R0 resection and local recurrence,overall survival,and disease-free survival did not differ significantly between the two groups.CONCLUSION The TRIANGLE technique is safe,with acceptable postoperative morbidities compared with standardized PD,but it does not improve prognosis for patients with resectable PDAC.

Knee Arthroplasty Incidence Rate vs. Revision of Knee Arthroplasty and Its Associated Comorbidities in Colombia

Introduction: Total knee arthroplasty (TKA) has been established as a transformative solution in the treatment of advanced degenerative diseases of the knee, such as osteoarthritis, rheumatoid arthritis, and posttraumatic arthritis. In this sense, TKA surgery, which seeks to replace the damaged joint with prosthetic components, has proven to be highly effective in relieving pain, improving joint function, and, ultimately, significantly increasing patients’ quality of life. The present study describes the TKA and revision knee arthroplasty (RKA) rates and, identifies the associated co morbidities in the Colombian context. Methods: A retrospective cohort study was carried out. It describes demographic and clinical characteristics between two groups of patients, TKA or RKA, and its association with mortality at 30 days, 90 days, or one year after the intervention. Results: The incidence rate of the population undergoing TKA was approximately 11.71 cases per 100,000 inhabitants. Furthermore, the incidence rate for revision knee arthroplasty (RKA) procedures in the same period was around 0.96 per 100,000 inhabitants. In both groups at 30 days postoperatively, a total mortality rate of 0.09%was recorded. When the follow-up was extended to 90 days, it increased to 0.15%;at one year postoperatively, it rose to 0.88%. Conclusion: Mortality after surgery was low in Colombia in 2019. Although RKA is a beneficial procedure, in certain circumstances, it was noted that it carries a higher risk compared to primary TKA. Our results emphasize the importance of careful evaluation of co morbidities and risk factors in patients undergoing these surgical procedures. The application of quality-of-life questionnaires should be considered in future studies on effectiveness and mortality for TKA and RKA in our country.

Psychiatric comorbidities in children with conduct disorder:a descriptive analysis of real-world data

To the editor:Two recent advisories from the US surgeon general have underscored the unprecedented public health crisis in youth mental health and emphasised the need for“timely data collection and research to identify and respond to youth mental health needs more rapidly”.1 Increased rates of suicidal behaviour,depression and anxiety symptoms and substance use.

Symptoms and comorbidities associated with abnormal levels of serum calcium,magnesium,and phosphate in the emergency department:a prospective observational study

Emergency departments(EDs)play a significant role in hospital healthcare systems.[1]According to the US Centers for Disease Control and Prevention,130 million individuals visited the ED in 2018.[2]A previous study has demonstrated that unnecessary laboratory tests did not change the management plan.[3]These actions led to ED overcrowding,causing consequences to patient outcomes.

Psychiatric morbidities in respiratory disorders:a cross sectional report providing insight into consultation-liaison psychiatry services in India

Background:Respiratory disorders are among the leading disorders contributing to extensive morbidity and mortality worldwide.Disorder variants,like Chronic Obstructive Pulmonary Diseases(COPD)in developed and developing countries,as well as infectious causes,like Tuberculosis(TB)in developing countries,contribute to significant disease burden.The literature points towards the coexistence of psychiatric disorders with respiratory disorders responsible for poorer outcomes.Despite the extensive burden of respiratory disorders and the presence of concurrent psychiatric disorders,studies focusing on their prevalence are limited in India.Methods:A cross-sectional psychiatric screening was carried out on sequential patients attending the tertiary respiratory unit over eight months.Those screened positive were interviewed in detail for psychiatric diagnosis and challenges in the management were discussed.Psychiatric diagnosis,pulmonary TB and medical comorbidity were assessed for correlation with demographic and clinical variables and analyzed by using the Chi-square test and logistic regression method using SPSS version 20.Results:Psychiatric morbidity was present in 100 out of 350 patients(28.57%).Tuberculosis was the most common diagnosis(46%)in subjects attending the respiratory clinic services while common mental disorders like depression,anxiety,and insomnia were the most common psychiatric concern(88%)in this study.Conclusion:Psychiatric disorders and medical morbidities are common in patients with respiratory disorders.Multiple factors determine the treatment adherence in both respiratory and psychiatric disorders.Screening for psychiatric disorders with the help of a consultation-liaison psychiatrist in respiratory units is recommended.Future studies should focus on developing dedicated psychiatry services to enhance overall outcomes in patients with respiratory disorders.

Comorbidities of prurigo nodularis in Chinese patients:A multicenter retrospective study

Prurigo nodularis(PN),as a subtype of chronic prurigo(CPG),is characterized by nodular lesions and severe pruritus,which signicantly affect patients’quality of life.[1]It has been observed that patients with PN often have comorbidities,including physical and mental diseases.[2]However,information on comorbidities in Chinese PN patients is lacking.This study aims toll this gap by using a representative patient population to provide comprehensive data on comorbidities in Chinese patients with PN.

Reflections on COPD comorbidities

To the Editor:Chronic obstructive pulmonary disease(COPD)is a common disease among the elderly,affecting over one-third of the elderly population worldwide.The progressive decline in lung function characteristic of COPD significantly impacts the quality of life and employability of affected individuals,resulting in a substantial direct and indirect socioeconomic burden.COPD frequently has comorbidities involving other organ systems.Virtually all elderly COPD patients present with one or more comorbid conditions,collectively exacerbating health and economic burdens.While viral and bacterial infections remain the most common triggers for COPD exacerbations(ECOPD).

Effects of adalimumab and secukinumab on comorbidities associated with metabolism in patients with plaque psoriasis

To the Editor:Psoriasis is often associated with comorbidities such as cardiovascular diseases,obesity,and metabolic syndrome(MS).However,the prevalence of abovementioned diseases in Chinese patients with plaque psoriasis is still unknown.Recently,biologics such as tumor necrosis alpha inhibitors,interleukin-17A inhibitors have been successfully used in the treatment of plaque psoriasis.However,the effects of biological treatment on comorbidities associated with metabolism are still controversial.Study on the relationship between the comorbidities associated with metabolism and plaque psoriasis and the effects of biologics are necessary.

Prevalence and Types of Comorbidities in Pneumoconiosis—China,2018–2021

Summary What is already known about this topic?Pneumoconiosis,recognized as one of the most detrimental occupational diseases in China,exhibits a multimorbidity profile due to a plethora of comorbidities and complications.These factors significantly influence the treatment outcomes,progression,prognosis,and overall quality of life of the afflicted patients.

Impact of comorbidities on the prognosis of pediatric vasovagal syncope

Vasovagal syncope(VVS)is the primary entity of neurally mediated syncope(NMS)in childhood,and its prognosis is usually considered benign.However,it is found in clini-cal practice that some children with VVS appear to have a frequent recurrence of syncope and poor response to treat-ment[1],which might seriously affect their quality of life[2].In recent years,an increasing number of comorbidities of VVS have been reported.Liao et al.found that 31%of pediatric patients with NMS suffered from allergic disease[3],and Vallejo M reported that more than 50%of patients had headaches[4].These comorbidities might make the clinical manifestations even more complex.However,until now,it has been unclear whether comorbidities are associated with the prognosis of children and adolescents suffering from VVS.Therefore,the present study was conducted to examine whether there is any impact of comorbidities on the prognosis of pediatric VVS to better understand the outcome and management of children and adolescents with VVS.

Comorbidities,clinical characteristics and outcomes of COVID‑19 in pediatric patients in a tertiary medical center in the Netherlands

Having pre-existing comorbidities is described as a risk factor for more severe disease in adult corona virus disease 2019(COVID-19)and in infections with SARS-CoV-1 and MERS-CoV[1].In adult SARS-CoV-2 infections,patients with pre-existing underlying comorbidities,such as chronic obstructive pulmonary disease,cardiovascular disease,diabetes and obesity,are more likely to have severe disease compared to healthy adults[2].An inconsistency is seen in current fndings on the association with comorbidities and pediatric COVID-19 severity.An important limitation in currently available studies is limited data:severe disease is rare in children compared to adults,and most studies describe COVID-19 severity merely by reporting intensive care unit(ICU)admission or mortality rates instead of detailed data on clinical presentation and outcomes.

Psychiatric comorbidities of epilepsy and COVID-19

Objective To evaluate the status and influencing factors of psychiatric comorbidities of patients with epilepsy(PWEs)in Hubei province during the outbreak of COVID-19.Methods From February 23,2020 to March 5,2020,a network questionnaire survey(including demographic characteristics,seizures,Generalized Anxiety Disorder Scale-7 score,Patient Health Questionnaire-9 score,Insomnia Severity Index score)was conducted a-mong 570 PWEs who visited the Epilepsy Center of Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology during April 1,2019 and January 20,2020.

Post Episiotomy Morbidity among Parturient in Alex Ekwueme Federal University Teaching Hospital Abakaliki, Ebonyi State

Background: Episiotomy is a very common obstetric surgery, and it could be associated with serious complications. However, these complications largely are not noticed due to the shift of attention from mother to baby, after a successful delivery. Objective: To identify the morbidities associated with episiotomies and factors associated with such morbidities. Method: This was a questionnaire based cross sectional descriptive study among women who attended the Obstetric Department of Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State, between 1st July and 31st Nov, 2023. The study population consisted of parturients who had episiotomies in their previous confinements, attending either the antenatal clinic or the postnatal clinic at Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State. Results: Macrosomia was the most common indication of episiotomy at a rate of 31.6%. The majority of episiotomies were performed on the parturients in their first confinement at a rate of 64.5% and the majority of repairs were performed by the Registrar at a rate of 65.0%. Informed consent was obtained from 45.79% of parturients while 54.21% were not informed before the episiotomy was administered. Only 55.3% of the parturient received analgesia before episiotomy was administered. The majority of the parturients had their episiotomy repaired between 10 - 15 minutes at a rate of 40.3%. Postoperative pain at the rate of 44.5% was the most common complication and dyspareunia as a form of sexual complication was the commonest at a rate of 31.3%. Conclusion: The parturient needs to be properly counselled before administration of episiotomy and adequate analgesia should be given, as episiotomy is a surgical procedure. Proper training of health workers on both the technique of administering and repairing episiotomy is important. Restrictive use of routine episiotomy in primigravidae is advised to reduce the rate of episiotomy.

Colon and rectal cancer:An emergent public health problem

Colorectal cancer ranks third globally,with a high mortality rate.In the United States,and different countries in Europe,organized population screenings exist and include people between 50 and 74 years of age.These screenings have allowed an early diagnosis and consequently an improvement in health indicators.Colon and rectal cancer(CRC)is a disease of particular interest due to the high global burden associated with it and the role attributed to prevention and early diagnosis in reducing morbidity and mortality.This study is a review of CRC pathology and includes the most recent scientific evidence regarding this pathology,as well as a diagnosis of the epidemiological situation of CRC.Finally,the recommendation from a public health perspective will be discussed in detail taking into account the context and the most current recommendations.

Multimorbidity and mortality among older patients with coronary heart disease in Shenzhen,China

BACKGROUND The current understanding of the magnitude and consequences of multimorbidity in Chinese older adults with coronary heart disease(CHD)is insufficient.We aimed to assess the association and population-attributable fractions(PAFs)between multimorbidity and mortality among hospitalized older patients who were diagnosed with CHD in Shenzhen,China.METHODS We conducted a retrospective cohort study of older Chinese patients(aged≥65 years)who were diagnosed with CHD.Cox proportional hazards models were used to estimate the associations between multimorbidity and all-cause and cardiovascular disease(CVD)mortality.We also calculated the PAFs.RESULTS The study comprised 76,455 older hospitalized patients who were diagnosed with CHD between January 1,2016,and August 31,2022.Among them,70,217(91.9%)had multimorbidity,defined as the presence of at least one of the predefined 14 chronic conditions.Those with cancer,hemorrhagic stroke and chronic liver disease had the worst overall death risk,with adjusted HRs(95%CIs)of 4.05(3.77,4.38),2.22(1.94,2.53),and 1.85(1.63,2.11),respectively.For CVD mortality,the highest risk was observed for hemorrhagic stroke,ischemic stroke,and chronic kidney disease;the corresponding adjusted HRs(95%CIs)were 3.24(2.77,3.79),1.91(1.79,2.04),and 1.81(1.64,1.99),respectively.All-cause mortality was mostly attributable to cancer,heart failure and ischemic stroke,with PAFs of 11.8,10.2,and 9.1,respectively.As for CVD mortality,the leading PAFs were heart failure,ischemic stroke and diabetes;the corresponding PAFs were 18.0,15.7,and 6.1,respectively.CONCLUSIONS Multimorbidity was common and had a significant impact on mortality among older patients with CHD in Shenzhen,China.Cancer,heart failure,ischemic stroke and diabetes are the primary contributors to PAFs.Therefore,prioritizing improved treatment and management of these comorbidities is essential for the survival prognosis of CHD patients from a holistic public health perspective.

Association of cardiometabolic multimorbidity with all-cause and cardiovascular disease mortality among Chinese hypertensive patients

BACKGROUND Hypertension usually clusters with multiple comorbidities.However,the association between cardiometabolic multimorbidity(CMM)and mortality in hypertensive patients is unclear.This study aimed to investigate the association between CMM and all-cause and cardiovascular disease(CVD)mortality in Chinese patients with hypertension.METHODS The data used in this study were from the China National Survey for Determinants of Detection and Treatment Status of Hypertensive Patients with Multiple Risk Factors(CONSIDER),which comprised 5006 participants aged 19–91 years.CMM was defined as the presence of one or more of the following morbidities:diabetes mellitus,dyslipidemia,chronic kidney disease,coronary heart disease,and stroke.Cox proportional hazard models were used to calculate the hazard ratios(HR)with 95%CI to determine the association between the number of CMMs and both all-cause and CVD mortality.RESULTS Among 5006 participants[mean age:58.6±10.4 years,50%women(2509 participants)],76.4%of participants had at least one comorbidity.The mortality rate was 4.57,4.76,8.48,and 16.04 deaths per 1000 person-years in hypertensive patients without any comorbidity and with one,two,and three or more morbidities,respectively.In the fully adjusted model,hypertensive participants with two cardiometabolic diseases(HR=1.52,95%CI:1.09–2.13)and those with three or more cardiometabolic diseases(HR=2.44,95%CI:1.71–3.48)had a significantly elevated risk of all-cause mortality.The findings were similar for CVD mortality but with a greater increase in risk magnitude.CONCLUSIONS In this study,three-fourths of hypertensive patients had CMM.Clustering with two or more comorbidities was associated with a significant increase in the risk of all-cause and cardiovascular mortality among hypertensive patients,suggesting more intensive treatment and control in this high-risk patient group.

Treatment of uveitis and scleritis patients in Malaysia

●AIM:To determine the common causes and visual outcome after treatment among uveitis and scleritis patients.●METHODS:This is a retrospective cohort observational study.All consecutive clinical records of patients with newly diagnosed uveitis and scleritis over a 4-year period,from Jan.1,2017 to Dec.31,2020,were analysed.Data was collected at the presentation and included a follow-up period of one year.●RESULTS:A total of 288 patients were recruited during the study period.Anterior uveitis was the most common anatomical diagnosis(50.0%)followed by panuveitis(25.0%),scleritis(13.5%),posterior uveitis(6.9%),and intermediate uveitis(4.5%).Viral Herpes was the most common cause of infectious cases,while Vogt-Koyanagi-Harada(VKH)disease and human leucocyte antigen(HLA)B27 spondyloarthropathy were the leading causes of identifiable non-infectious cases.Majority of patients presented with unilateral,non-granulomatous uveitis with an absence of hypopyon.Anatomical locations like posterior uveitis and panuveitis,and visual acuity worse than 3/60 at presentation were the factors associated with poor visual outcomes(P<0.05).About 60%of patients had an identifiable cause for the uveitis and scleritis,with nearly equal distribution of infectious(n=85,29.5%)and noninfectious causes(n=84,29.2%).About 14.5%of patients were clinically blind at 1y of follow-up.The most common complication in our uveitis patients was glaucoma(47.5%),followed by cystoid macula oedema(18.9%)and cataract(13.9%).●CONCLUSION:Uveitis and scleritis are important causes of ocular morbidity.They are potentially blinding diseases which can have a good outcome if diagnosed and treated early.

Cardiometabolic and panvascular multimorbidity associated with motoric cognitive risk syndrome in older adults

Background Motoric cognitive risk(MCR)syndrome as a pre-dementia syndrome often co-occurring with chronic health condi-tions.This study aims to investigate the prevalence of MCR and its association with cardiometabolic and panvascular multimorb-idity among older people living in rural China.Methods This population-based study included 1450 participants who were aged≥60 years(66.2%women)and who underto-ok the second wave examination of the Confucius Hometown Aging Project in Shandong,China when information to define MCR was collected.Data were collected through in-person interviews,clinical examinations,and laboratory tests.Cardiometabolic and pa-nvascular multimorbidity were defined following the international criteria.MCR was defined as subjective cognitive complaints and slow gait speed in individuals free of dementia and functional disability.Multivariable logistic regression models were used to exa-mine the associations of MCR with multimorbidity.Results MCR was present in 6.3%of all participants,and the prevalence increased with advancing age.Cerebrovascular disea-se,ischemic heart disease,heart failure,and increased serum cystatin C were associated with increased likelihoods of MCR(mult-ivariable-adjusted odds ratio range:1.90-3.02,P<0.05 for all).Furthermore,there was a dose-response relationship between the nu-mber of cardiometabolic diseases and panvascular diseases and the likelihood of MCR.The multivariable-adjusted odds ratio(95%CI)of MCR associated with cardiometabolic and panvascular multimorbidity were 2.47(1.43-4.26)and 3.85(2.29-6.47),respectiv-ely.Conclusions Older adults with cardiometabolic and panvascular multimorbidity are at a higher likelihood of MCR.These fin-dings may have implications for identifying older adults at pre-dementia state as targets for early preventive interventions to delay dementia onset.

Intensive care unit-acquired weakness and mechanical ventilation:A reciprocal relationship

Intensive care unit-acquired weakness(ICU-AW;ICD-10 Code:G72.81)is a syndrome of generalized weakness described as clinically detectable weakness in critically ill patients with no other credible cause.The risk factors for ICU-AW include hyperglycemia,parenteral nutrition,vasoactive drugs,neuromuscular blocking agents,corticosteroids,sedatives,some antibiotics,immobilization,the disease severity,septicemia and systemic inflammatory response syndrome,multiorgan failure,prolonged mechanical ventilation(MV),high lactate levels,older age,female sex,and pre-existing systemic morbidities.There is a definite association between the duration of ICU stay and MV with ICU-AW.However,the interpretation that these are modifiable risk factors influencing ICU-AW,appears to be flawed,because the relationship between longer ICU stays and MV with ICU-AW is reciprocal and cannot yield clinically meaningful strategies for the prevention of ICU-AW.Prevention strategies must be based on other risk factors.Large multicentric randomized controlled trials as well as meta-analysis of such studies can be a more useful approach towards determining the influence of these risk factors on the occurrence of ICU-AW in different populations.

Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center:Value of tailored peri-pancreatectomy protocols

BACKGROUND Pancreaticoduodenectomy(PD)is a technically complex operation,with a re-latively high risk for complications.The ability to rescue patients from post-PD complications is as a recognized quality measure.Tailored protocols were instituted at our low volume facility in the year 2013.AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1,2013 and June 30,2023.Stan-dardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications,and the modified Clavien-Dindo classification was used to classify post-PD complications.RESULTS Over the study period,113 patients at a mean age of 57.5 years(standard deviation[SD]±9.23;range:30-90;median:56)underwent PDs at this facility.Major complications were recorded in 33(29.2%)patients at a mean age of 53.8 years(SD:±7.9).Twenty-nine(87.9%)patients who experienced major morbidity were salvaged after aggre-ssive treatment of their complication.Four(3.5%)died from bleeding pseudoaneurysm(1),septic shock secondary to a bile leak(1),anastomotic leak(1),and myocardial infarction(1).There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores≤2(93.3%vs 25%;P=0.0024).CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD.Despite low volumes at our facility,we demonstrated that 87.9%of patients were rescued from major complications.We attributed this to several factors including development of rescue protocols,the competence of the pancreatic surgery teams and continuous,and adaptive learning by the entire institution,cul-minating in the development of tailored peri-pancreatectomy protocols.