Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

: The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990)

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

The association between breast cancer and diabetes mellitus

Problēmas būtība: Saslimstība ar cukura diabētu, kā arī ar krūts vēzi ik gadu pieaug visā pasaulē. Pēdējo 150 gadu laikā veikti daudzi pētījumi, kas atklāj izteiktu saistību starp šīm slimībām. Ir nepieciešama detalizētāka izpēte analizējot kopējos slimību attīstības mehānismus, kā arī retrospektīvi izvērtējot krūts vēža gaitu un iznākumu pacientēm ar cukura diabētu, salīdzinājumā ar pacientēm bez cukura diabēta. Darba mērķis: noskaidrot, vai saslimstība ar cukura diabētu ietekmē krūts vēža gaitu un iznākumu, kā arī salīdzināt pētījuma rezultātus ar literatūrā pieejamajiem datiem. Darba metode: Pētījums veikts retrospektīvi analizējot medicīniskās kartes no Latvijas Onkoloģijas Centra un Paula Stradiņa Klīniskās universitātes slimnīcas Onkoloģijas klīnikas, laika posmā no 1994. līdz 2014. gadam. Pētījumā iekļautas 96 pacientes. Rezultāti: Krūts vēža un cukura diabēta grupā blakusslimības bija 92.2% pacienšu, turpretī grupā bez cukura diabēta – 61.1% pacienšu. Pastāv statistiski ticama saistība, ka krūts vēža un cukura diabēta grupā biežāk bija sastopama arteriālā hipertensija (p=0.01), hroniska sirds mazspēja (p=0.01) un taukainā hepatoze (p=0.00). Glikozes līmenis abās grupās samazinājās krūts vēža terapijas laikā, salīdzinot ar glikozes līmeni pirms krūts vēža terapijas. Pacientu grupā ar krūts vēzi un cukura diabētu komplikācijas bija sastopamas 47.6% pacienšu, taču grupā bez cukura diabēta 27.8% pacienšu. Grupā ar krūts vēzi bez cukura diabēta atklājās statistiski ticama saistība ar limfostāzi (p=0.004). Otrā grupā statistiska ticamība bija plaušu fibrozes komplikācijai (p=0.000). Novēroja, ka mirstības rādītāju rezultāti abās grupās bija ļoti līdzīgi un nepastāvēja izteiktas atšķirības starp šiem rādītājiem. Grupā ar krūts vēzi un cukura diabētu vidējā dzīvildze bija 6.4 gadi, bet grupā ar krūts vēzi tā bija 4.8 gadi. Secinājumi: 1.Pacientēm ar cukura diabētu un krūts vēzi no riska faktoriem procentuāli biežāk bija aptaukošanās. 2.Pacientēm ar cukura diabētu un krūts vēzi bija vairāk blakusslimību. Citas lokalizācijas vēža prevalence bija nedaudz izteiktāka pacienšu grupā bez cukura diabēta. 3.Abās pētāmajās grupās krūts vēža terapija samazināja glikozes līmeni asinīs. 4.Cukura diabēta terapija neietekmēja krūts vēža komplikācijas. 5.Vairāk komplikāciju bija krūts vēža un cukura diabēta grupā. 6.Biežāk slimības progresiju novēroja pacientēm krūts vēža un cukura diabēta grupā, taču nepastāv statistiski ticamas saistības. Mirstības rādītāju rezultāti abās grupās bija ļoti līdzīgi un nepastāv izteiktas atšķirības.Introduction: Incidence both in diabetes and breast cancer is increasing every year around the world. Over the past 150 years, there has been a lot of research showing a strong connection between diabetes and breast cancer. There is a need for more detailed study of these two diseases, both in understanding common mechanisms and retrospectively assess breast cancer course and outcomes in patients with diabetes, compared with patients without diabetes. Aim: To find out whether the incidence of diabetes affects breast cancer progression and outcomes, and to compare the results of this study with the available literature data. Materials and methods: The study was a retrospective analysis of medical case histories of Oncology Centre of Latvia and Oncology Clinic of Pauls Stradins Clinical University Hospital during the period from 1994 to 2014. The study included 96 patients. Results: Patient group with breast cancer and diabetes comorbidities were present in 92.2% of patients, whereas the group without diabetes – 61.1% of patients. There is a statistically significant association that in breast cancer and diabetes group there is higher incidence in hypertension (p=0.01), chronic heart failure (p=0.01), fatty liver disease (p=0.00). Glucose in both groups decreases during breast cancer treatment, in comparison to a sugar level before breast cancer therapy. In a group of patients with breast cancer and diabetes, complications occurred in 47.6% of patients, but in the group without diabetes 27.8% of patients. In a group of patients with breast cancer without diabetes, there was no statistically significant association between lymphostasis (p = 0.004). The second group had statistically significant association of pulmonary fibrosis (p = 0.000). Mortality rate results in both groups are very similar and there are no significant differences. In the group with breast cancer and diabetes, the median survival rate is 6.4 years, but the group with breast cancer it is 4.8 years. Conclusion: 1.From risk factors, obesity was more common in patient group with diabetes and breast cancer. 2.Patients with breast cancer and diabetes had more co-morbidities. Other malignant disease prevalence was slightly higher in the group of patients with breast cancer. 3.In both study groups, breast cancer therapy reduced blood glucose levels. 4.Diabetes therapy had no effect on breast cancer complications. 5.Breast cancer and diabetes group had more complications than the second group. 6.Disease progression was more frequent in a group with breast cancer and diabetes, but it was not statistically significant. Mortality rate results in both groups are very similar and there are no significant differences between these indicators

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

IMPORTANCE Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.OBJECTIVE To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.DESIGN, SETTINGS, AND PARTICIPANTS This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.MAIN OUTCOMES Mortality and morbidity after EC.RESULTS Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P <.001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).CONCLUSIONS AND RELEVANCE This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC