Diversity and ethics in trauma and acute care surgery teams: results from an international survey

Background Investigating the context of trauma and acute care surgery, the article aims at understanding the factors that can enhance some ethical aspects, namely the importance of patient consent, the perceptiveness of the ethical role of the trauma leader, and the perceived importance of ethics as an educational subject. Methods The article employs an international questionnaire promoted by the World Society of Emergency Surgery. Results Through the analysis of 402 fully filled questionnaires by surgeons from 72 different countries, the three main ethical topics are investigated through the lens of gender, membership of an academic or non-academic institution, an official trauma team, and a diverse group. In general terms, results highlight greater attention paid by surgeons belonging to academic institutions, official trauma teams, and diverse groups. Conclusions Our results underline that some organizational factors (e.g., the fact that the team belongs to a university context or is more diverse) might lead to the development of a higher sensibility on ethical matters. Embracing cultural diversity forces trauma teams to deal with different mindsets. Organizations should, therefore, consider those elements in defining their organizational procedures. Level of evidence Trauma and acute care teams work under tremendous pressure and complex circumstances, with their members needing to make ethical decisions quickly. The international survey allowed to shed light on how team assembly decisions might represent an opportunity to coordinate team member actions and increase performance

Ensayo clínico fase I-IIa para valorar la factibilidad y seguridad del hidrogel de alginato de calcio en el tratamiento de las fístulas anales de origen criptoglandular

Introducción. A día de hoy, la enfermedad fistulosa perianal compleja constituye un reto para el cirujano colorrectal, dado que no existe la técnica quirúrgica ideal que consiga un tratamiento efectivo sin recidiva a largo plazo a la vez que preserve la continencia. En los últimos años han surgido diferentes métodos de sellado de los trayectos fistulosos, así como numerosas publicaciones acerca de la utilización del hidrogel de alginato de calcio en el contexto de la ingeniería de tejidos. Por ello, proponemos este trabajo, con el objetivo de analizar la factibilidad y seguridad de este agente para el sellado de las fístulas anales complejas de origen criptoglandular. Material y método. Diseñamos un ensayo clínico piloto prospectivo fase I-IIa, con un tamaño muestral de veinte pacientes, acorde a este tipo de estudio. El muestreo fue de tipo no probabilístico, teniendo en cuenta a todos los pacientes que acudieron a nuestras consultas y que cumplieron los criterios de selección. Para el análisis de datos se utilizó el paquete IBM® SPSS® Statistics versión 25, considerando significancia estadística a p <0,05. Resultados. Nuestra muestra estuvo conformada de forma mayoritaria por varones, con sobrepeso u obesidad, con una media de edad de 50,25 años y el 75% de ellos asociaba alguna comorbilidad médica. En cuanto a las características de la fístula, la mayoría fueron persistentes, seguido de primarias y en último lugar recidivadas. Todas se consideraron complejas, bien por ser transesfinterianas o, en un caso, por asociar incontinencia fecal. El procedimiento se consideró factible en el 100% de los casos. Se analizaron el perfil de seguridad y la eficacia clínica tras un periodo de seguimiento de un año. La tasa de curación (parcial o completa) fue del 65%, teniendo lugar la respuesta mayoritariamente en los seis primeros meses tras el tratamiento. Estos hallazgos se constataron también en ecografía endoanal, con una tasa de concordancia Kappa de Cohen de 0,89. Se objetivó relación estadísticamente significativa entre la curación y la presencia y número de comorbilidades, así como con el antecedente de tratamiento domiciliario. La presencia de supuración o emisión de otro líquido diferente a los seis meses del tratamiento se asoció con menores tasas de curación al año. El dolor medido mediante la Escala Visual Analógica, la incontinencia medida mediante el score de Wexner y la calidad de vida analizada mediante el cuestionario de calidad de vida SF-36 versión 2 mostraron ligeras mejorías, aunque no estadísticamente significativas. Se describió una incidencia acumulada de acontecimientos adversos relacionados con el tratamiento del 35%, ninguno de ellos grave. Sólo tuvo lugar un acontecimiento adverso grave, al precisar uno de los pacientes exploración anal bajo anestesia ante la sospecha de un absceso perianal que no se confirmó durante la cirugía. Este acontecimiento adverso fue considerado no relacionado, al haber ocurrido tras más de un mes del tratamiento. La mayoría de los acontecimientos adversos fueron moderados (68,2%) o leves (27,3%). Discusión. El sellado mediante hidrogel de alginato de calcio ha resultado ser un procedimiento factible, al igual que otros procedimientos de sellado descritos en la literatura, como la fibrina y los factores de crecimiento derivados de plaquetas. El perfil de seguridad que presenta es aceptable, sin acontecimientos adversos relacionados de tipo grave y sin poder establecer comparaciones con los resultados de la literatura debido a grandes diferencias en cuanto a su registro. La eficacia, tanto clínica como ecográfica, del 65% tras un año de la intervención, también resultó encontrarse en rango aceptable respecto a las cifras publicadas en la literatura, si bien no era uno de los objetivos principales de nuestro estudio. Nosotros hemos obtenido pequeñas mejorías, no estadísticamente significativas y menos marcadas, respecto a las publicadas en algunos trabajos en relación al dolor, continencia y calidad de vida. Si bien nuestros resultados son alentadores y nos obligan a continuar investigando al respecto, nuestro trabajo presenta como limitaciones el pequeño tamaño muestral y la ausencia de aleatorización. Conclusiones. Parece que el empleo del hidrogel de alginato de calcio en el tratamiento de las fístulas anales complejas de origen criptoglandular es un procedimiento factible, con un perfil de seguridad aceptable y con tasas de curación prometedoras, que nos animan a continuar investigando al respecto

Role of Nitric Oxide in Gene Expression Regulation during Cancer: Epigenetic Modifications and Non-Coding RNAs

Nitric oxide (NO) has been identified and described as a dual mediator in cancer according to dose-, time- and compartment-dependent NO generation. The present review addresses the different epigenetic mechanisms, such as histone modifications and non-coding RNAs (ncRNAs), miRNA and lncRNA, which regulate directly or indirectly nitric oxide synthase (NOS) expression and NO production, impacting all hallmarks of the oncogenic process. Among lncRNA, HEIH and UCA1 develop their oncogenic functions by inhibiting their target miRNAs and consequently reversing the inhibition of NOS and promoting tumor proliferation. The connection between miRNAs and NO is also involved in two important features in cancer, such as the tumor microenvironment that includes key cellular components such as tumor-associated macrophages (TAMs), cancer associated fibroblasts (CAFs) and cancer stem cells (CSCs).This research was funded by the Institute of Health Carlos III (ISCiii) (PI19/01266) and Andalusian Ministry of Health (PI-0216-2020). P de la C-O was supported by the FPU predoctoral fellowship (FPU17/00026) from the Ministry of Education, Culture and Sports. E N-V was supported by the predoctoral i-PFIS IIS-enterprise contract in science and technologies in health (IFI18/00014) from the ISCiii. S D-B was supported by the “Rio Hortega” postdoctoral contract (CM19/00151) from the ISCiii. We thank the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd), founded by the ISCIII and co-financed by European Regional Development Fund “A way to achieve Europe” ERDF for their financial support.Ye

Impact of nitric oxide in liver cancer microenvironment.

The pro- or antitumoral properties of nitric oxide (NO) are dependent on local concentration, redox state, cellular status, duration of exposure and compartmentalization of NO generation. The intricate network of the tumor microenvironment (TME) is constituted by tumor cells, stromal and immune cells surrounded by active components of extracellular matrix that influence the biological behavior and, consequently, the treatment and prognosis of cancer. The review describes critical events in the crosstalk of cellular and stromal components in the TME, with special emphasis in the impact of NO generation in the regulation of hepatocellular carcinoma (HCC). The increased expression of nitric oxide synthase (NOS) in tumors and NO-end products in plasma have been associated with poor prognosis of cancer. We have assessed the level of the different isoforms of NOS in tumors and its relation to cell proliferation and death markers, and cell death receptor expression in tumors, and apoptotic markers and ligands of TNF-α receptor family in blood from a cohort of patients with HCC from different etiologies submitted to orthotopic liver transplantation (OLT). The high levels of NOS2 in tumors were associated with low plasma concentration of apoptotic markers (M30 and M65), FasL and TNF-α in HCV patients. By contrast, the low levels of NOS2 in tumors from alcohol-derived patients was associated with increased Trail-R1 expression in tumors, and circulating Trail levels compared to observed in plasma from HCV- and alcohol + HCV-derived patients. This study reinforces the association between increased NOS2 expression and potential risk of low patients' survival in HCC. However, a differential functional relevance of NOS expression in HCC seems to be influenced by etiologies

Impact of nitric oxide in liver cancer microenvironment

The pro- or antitumoral properties of nitric oxide (NO) are dependent on local concentration, redox state, cellular status, duration of exposure and compartmentalization of NO generation. The intricate network of the tumor microenvironment (TME) is constituted by tumor cells, stromal and immune cells surrounded by active com ponents of extracellular matrix that influence the biological behavior and, consequently, the treatment and prognosis of cancer. The review describes critical events in the crosstalk of cellular and stromal components in the TME, with special emphasis in the impact of NO generation in the regulation of hepatocellular carcinoma (HCC). The increased expression of nitric oxide synthase (NOS) in tumors and NO-end products in plasma have been associated with poor prognosis of cancer. We have assessed the level of the different isoforms of NOS in tumors and its relation to cell proliferation and death markers, and cell death receptor expression in tumors, and apoptotic markers and ligands of TNF-α receptor family in blood from a cohort of patients with HCC from different etiologies submitted to orthotopic liver transplantation (OLT). The high levels of NOS2 in tumors were associated with low plasma concentration of apoptotic markers (M30 and M65), FasL and TNF-α in HCV patients. By contrast, the low levels of NOS2 in tumors from alcohol-derived patients was associated with increased Trail R1 expression in tumors, and circulating Trail levels compared to observed in plasma from HCV- and alcohol + HCV-derived patients. This study reinforces the association between increased NOS2 expression and potential risk of low patients’ survival in HCC. However, a differential functional relevance of NOS expression in HCC seems to be influenced by etiologies

Which multi-trauma patients benefit from performing a total-body CT?

Peer reviewe

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. METHODS: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. RESULTS: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. CONCLUSIONS: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands

Surgeons’ practice and preferences for the anal fissure treatment: results from an international survey

The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons' practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants' demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results

Surgeons' perspectives on artificial intelligence to support clinical decision-making in trauma and emergency contexts: results from an international survey

Background: Artificial intelligence (AI) is gaining traction in medicine and surgery. AI-based applications can offer tools to examine high-volume data to inform predictive analytics that supports complex decision-making processes. Time-sensitive trauma and emergency contexts are often challenging. The study aims to investigate trauma and emergency surgeons' knowledge and perception of using AI-based tools in clinical decision-making processes. Methods: An online survey grounded on literature regarding AI-enabled surgical decision-making aids was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to 917 WSES members through the society's website and Twitter profile. Results: 650 surgeons from 71 countries in five continents participated in the survey. Results depict the presence of technology enthusiasts and skeptics and surgeons' preference toward more classical decision-making aids like clinical guidelines, traditional training, and the support of their multidisciplinary colleagues. A lack of knowledge about several AI-related aspects emerges and is associated with mistrust. Discussion: The trauma and emergency surgical community is divided into those who firmly believe in the potential of AI and those who do not understand or trust AI-enabled surgical decision-making aids. Academic societies and surgical training programs should promote a foundational, working knowledge of clinical AI