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Objectives Methods Results Conclusion While emergency cholecystectomy is the preferred treatment for acute cholecystitis, conservative management can be used as a bridge to definitive surgical management in situations where emergency surgical services are limited. The objective of this systematic review is to identify factors associated with conservative management failure as defined as either failed resolution of symptoms on initial presentation, or the recurrence of symptoms whilst awaiting an elective cholecystectomy. This study aims to allow clinicians to make evidence‐based recommendations for conservative versus operative management.A systematic review of the Medline database was conducted in May 2022 to identify studies analysing the success of non‐operative management of acute cholecystitis. Two independent reviewers selected studies based on predefined criteria, and the risk of bias was evaluated. Out of the initial 1344 studies retrieved, 12 studies met the inclusion criteria.Factors significantly associated with persistence of symptoms in at least one study on multivariable analysis included diabetes mellitus, age >70, tachycardia, elevated temperature, elevated white cell count >15 000/uL and a distended gallbladder >5 cm. Factors significantly associated with recurrence of symptoms included Age <40 or >80, male sex, acute cholecystitis grade 2 or 3, elevated creatinine, serum albumin <4 g/dL, thickened gallbladder wall >5 mm.Several factors have been identified which may facilitate future evidence‐based recommendations for tailored management strategies for patients with acute cholecystitis. [ABSTRACT FROM AUTHOR]

Micron-size ceramic waste powder (< 75 μm and 75–150 μm) was used as the carrier in a high-concentration powder carrier bio-fluidized bed (HPB) to treat simulated overflow sewage (CSOs). The sludge extracellular polymers (EPS), electron transfer capacity of EPS, nitrogen removal pathways, and microbiological characteristics were analyzed to gain insights into the nitrogen removal pathways and mechanisms. The results showed that only the effluent from the HPB (< 75 μm) could meet the stringent pollutant discharge standards in China of 50 mg/L for CODCr and 15 mg/L for total nitrogen from beginning to end. Meanwhile, the electrochemical performance tests indicated that the electron accepting and donating capacities of the sludge EPS in the HPB (< 75 μm) were 42.75% and 32.73% higher than those in the conventional activated sludge, meaning that ceramic powder carriers can increase the extracellular electron transfer capacity of the sludge and accelerate the denitrification process. Also, metagenomics analysis results showed that the relative abundances of the denitrification-related Nor genes were 28–39% higher in the HPB (< 75 μm) and HPB (75–150 μm) than in the conventional activated sludge (CAS). These results show that ceramic waste powders have the potential to be used as carriers in HPB systems to treat CSOs. [ABSTRACT FROM AUTHOR]

Introduction: Adoption of robotic liver resections has been gradually increasing throughout the HPB surgical community over the past decade. Currently there is limited literature which demonstrates a significant benefit of robotic surgery for major hepatectomies over open or laparoscopic. As one of the first centers to develop a robotic HPB program, we have experienced improved outcomes over time with increasing utilization of robotics. Herein, we present our 10-year experience and outcomes for major robotic liver resections. Methods: From 2012 to 2022, 361 robotic liver procedures were performed, including 100 major hepatectomies. A retrospective data review of the electronic medical record was performed evaluating outcomes after robotic major hepatectomy. Outcomes for the first 50 cases (Group A) and second 50 cases (Group B) were compared to identify any improvements in practice. Demographic and clinical outcome variables were analyzed. Data were assessed for normality, and Wilcoxon rank-sum, χ2 tests, and a logistic regression model were performed appropriate for the data. Stata v.17 was utilized, and significance was set as p <.05. Results: There was no difference in median operative time (258 vs 256 min), EBL (500 vs 500 mL), median LOS (5 vs 3.5 days), 90-day readmission (14% vs 24%), major complications (14% vs 20%), and 90-day mortality (6% vs 4%) between early and late cases, respectively. ICU admissions and conversion rates were significantly lower in group B (14.0% vs 48.0%), while expert level difficulty indices were higher (82% vs 58%). Conclusion: Development of a robotic liver program with good outcomes is feasible over time. Our data suggest that our institutional learning curve for robotic major hepatectomy plateaued at approximately 50 cases. [ABSTRACT FROM AUTHOR]

Simple Summary: This review examines the available data that have been reported on diversity within the field of hepatobiliary and pancreas surgery in the United States. The authors review the barriers surmounted by successful hepatobiliary and pancreas surgeons from backgrounds that are historically underrepresented in medicine. The authors found that barriers exist at each point of training: starting from admission into medical school, continuing into surgical residency programs and surgical fellowship programs, and into surgical practice. A pattern emerged that revealed the attrition of underrepresented students at each progression toward hepatobiliary and pancreas surgical practice. The authors further review challenges inherent to workforce homogeneity and introduce evidence-based solutions that promote the achievement of excellence via diversity, equity, and inclusion in hepatopancreatobiliary surgery and beyond. Diversity is a catalyst for progress that prevents institutional stagnation and, by extension, averts descent to mediocrity. This review focuses on the available data concerning hepatopancreatobiliary (HPB) surgical workforce demographics and identifies evidence-based strategies that may enhance justice, equity, diversity, and inclusion for HPB surgeons and their patients. We report that the current United States HPB surgical workforce does not reflect the population it serves. We review data describing disparity-perpetuating hurdles confronting physicians from minority groups underrepresented in medicine at each stage of training. We further examine evidence showing widespread racial and socioeconomic disparities in HPB surgical care and review the effects of workforce diversity and physician–patient demographic concordance on healthcare outcomes. Evidence-based mitigators of structural racism and segregation are reviewed, including tailored interventions that can address social determinants of health toward the achievement of true excellence in HPB surgical care. Lastly, select evidence-based data driving surgical workforce solutions are reviewed, including intentional compensation plans, mentorship, and sponsorship. [ABSTRACT FROM AUTHOR]

Aim of the study: This study aims to evaluate supervised machine learning algorithms in predicting 90 days post-operative mortality in gastrointestinal and HPB surgeries and comparing them with standard logistic regression methods. Methods: We evaluated various supervised machine learning classification algorithms like gradient boosting, K-nearest neighbours, random forest, and support vector machines with standard logistic regression methods. We used accuracy and the Receiver operating curve to compare the methods. 60% of the data were used for training, 20% for validation and 20% for testing. We used JASP 0.16.04 by the University of Amsterdam to run machine learning algorithms and statistical analysis. Results: We used data from 504 patients who have undergone gastrointestinal and hepatopancreatic biliary surgery between April 2016 and March 2023. We analyzed algorithms for predicting 90 days post-operative mortality based on features like Major surgeries, Surgeries for malignancies, age, CDC grade of surgeries, Intraoperative hypotension, Open vs Laparoscopic surgeries, ASA grade, Emergency surgeries, Operative time, Intraoperative blood product used, colorectal surgeries, small intestinal surgeries, HPB surgeries, upper gastrointestinal surgeries and hernia. Test accuracies were 96% for gradient boosting, 90% for K-nearest neighbours, 96% for the random forest, 94% for support vector and Areas under the ROC curve were 0.802 for gradient boosting, 0.489 for K-nearest neighbours, 0.934 for random forest and 0.5 for support vector algorithms. Accuracy and Area under the ROC curve with standard logistic regression method were 94% and 0.757. Features of importance in decreasing order were ASA, operative times, blood products, small bowel surgeries and Age. Conclusion: Supervised machine learning algorithms particularly gradient boosting and random forest predicted 90 days postoperative mortality more accurately than logistic regression and such models can be part of the preoperative evaluation in gastrointestinal and HPB surgeries. [ABSTRACT FROM AUTHOR]

Background: Malnutrition has been linked to the development of hepatopancreatobiliary (HPB) cancer. We sought to examine the association between food swamps and food deserts on surgical outcomes of patients with HPB cancer. Methods: Patients who underwent surgery for HPB cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. Patient-level data were linked to the United States Department of Agriculture data on food swamps and deserts. Multivariable regression was performed to examine the association between the food environment and outcomes. Results: Among 53,426 patients, patients from the worse food environment were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with high social vulnerability. Following surgery, the overall incidence of textbook outcome (TO) was 41.6% (n = 22,220). Patients residing in the worse food environments less often achieved a TO versus individuals residing in the healthiest food environments (food swamp: 39.4% vs. 43.9%; food desert: 38.5% vs 42.2%; p < 0.05). On multivariable analysis, individuals residing in the poorest food environments were associated with lower odds of achieving TO compared with individuals living in healthiest food environments (food swamp: OR 0.83, 95%CI 0.75–0.92, food desert: OR 0.86, 95%CI 0.76–0.97; both p < 0.05). Conclusion: The surrounding food environment of patients may serve as a modifiable socio-demographic risk factor that contributes to disparities in surgical outcomes of HPB cancer. [ABSTRACT FROM AUTHOR]

Introduction: Food insecurity (FI) may predispose individuals to suboptimal nutrition, leading to chronic disease and poor health outcomes. We sought to assess the impact of county-level FI on postoperative outcomes among patients undergoing resection of hepatopancreaticobiliary (HPB) cancer. Methods: Patients who were diagnosed with HPB cancer between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Data on annual county-level FI were obtained from the Feeding America: Mapping the Meal Gap report and were categorized into tertiles. Textbook outcome was defined as no extended length of stay, perioperative complications, 90-day readmission, and 90-day mortality. Multiple logistic regression and Cox regression models were used to assess outcomes and survival relative to FI. Results: Among 49,882 patients (hepatocellular: n = 11,937, 23.9%; intrahepatic cholangiocarcinoma: n = 2111, 4.2%; extrahepatic cholangiocarcinoma: n = 4047, 8.1%; gallbladder: n = 2853, 5.7%; pancreatic: n = 28,934, 58.0%), 6702 (13.4%) patients underwent a surgical resection. Median age was 75 years (interquartile range 69–82), and most patients were male (n = 25,767, 51.7%) and self-identified as White (n = 36,381, 72.9%). Overall, 5291 (10.6%) and 39,664 (79.5%) individuals resided in low or moderate FI counties, respectively, while 4927 (9.8%) patients resided in high FI counties. Achievement of textbook outcome (TO) was 56.3% (n = 6702). After adjusting for competing risk factors, patients residing in high FI counties had lower odds to achieve a TO versus individuals living in low FI counties (odds ratio 0.69, 95% confidence interval [CI] 0.54–0.88, p = 0.003). In addition, patients residing in moderate and high FI counties had a greater risk of mortality at 1- (referent, low, moderate: hazard ratio [HR] 1.09, 95% CI 1.05–1.14; high: HR 1.14, 95% CI 1.08–1.21), 3- (referent, low, moderate: HR 1.09, 95% CI 1.05–1.14; high: HR 1.14, 95% CI 1.08–1.21), and 5- (referent, low, moderate: HR 1.05, 95% CI 1.01–1.09; high: HR 1.07, 95% CI 1.02–1.13) years versus individuals from low FI counties. Conclusions: FI was associated with adverse perioperative outcomes and long-term survival following resection of an HPB malignancy. Interventions directed towards mitigating nutritional inequities are needed to improve outcomes among vulnerable HPB populations. [ABSTRACT FROM AUTHOR]

Background: Hepatopancreato and biliary (HPB) tumors represent some of the leading cancer-related causes of death worldwide, with the majority of patients undergoing surgery in the context of a multimodal treatment strategy. Consequently, the implementation of an accurate risk stratification tool is crucial to facilitate informed consent, along with clinical decision making, and to compare surgical outcomes among different healthcare providers for either service evaluation or clinical audit. Perioperative troponin levels have been proposed as a feasible and easy-to-use tool in order to evaluate the risk of postoperative myocardial injury and 30-day mortality. The purpose of the present study is to validate the perioperative troponin levels as a prognostic factor regarding postoperative myocardial injury and 30-day mortality in Greek adult patients undergoing HPB surgery. Method: In total, 195 patients undergoing surgery performed by a single surgical team in a single tertiary hospital (2020–2022) were included. Perioperative levels of troponin before surgery and at 24 and 48 h postoperatively were assessed. Model accuracy was assessed by observed-to-expected (O:E) ratios, and area under the receiver operating characteristic curve (AUC). Survival at one year postoperatively was compared between patients with high and normal TnT levels at 24 h postoperatively. Results: Thirteen patients (6.6%) died within 30 days of surgery. TnT levels at 24 h postoperatively were associated with excellent discrimination and provided the best-performing calibration. Patients with normal TnT levels at 24 h postoperatively were associated with higher long-term survival compared to those with high TnT levels. Conclusions: TnT at 24 h postoperatively is an efficient risk assessment tool that should be implemented in the perioperative pathway of patients undergoing surgery for HPB cancer.

Background: Robotic procedures are gaining more and more importance in visceral surgery and seem to develop into an indispensable tool in minimally invasive visceral surgery. In 2020 the COVID-19 pandemic caused unexpected changes in daily surgical routines with still ongoing challenges. We evaluated the impact of the COVID-19 pandemic on robotic visceral procedures and the associated training provided in Germany. Material and methods: We performed a thorough evaluation of German hospitals and identified 89 surgical departments performing robotic visceral procedures. After extensive topic-related literature search an online questionnaire was developed. It included 35 questions referring to all relevant topics on robotic surgery, such as training programs and influence of the COVID-19 pandemic. The survey was sent via email three times to each department. Descriptive and subgroup analysis were performed. Results: We reported a response to our questionnaire from 22 (24.7%) surgical departments and17 questionnaires were analyzable. The vast majority of them weresurgical departments of university hospitals (58.8%), 17.6% maximum care clinics and 23.5% main care clinics. Robotic procedures were performed for the upper gastrointestinal tract (UGI 88.2%), the hepatopancreaticobiliary system (HPB 82.4%), in the colorectal region (94.1%) and for hernias (35.3%). The relative proportion of robotic operations in comparison to all visceral procedures was between 0.3% and 15.4%. The average conversion rate was 4.6 ± 3.2% referring to 2020. All participating clinics used the robotic DaVinci® system (Intuitive Surgical Inc., CA, USA). In summary 22 robotic systems were used mainly in an interdisciplinary setting (82.4%). For teaching purposes, 7 departments (41.2%) provided a second robotic console. On average 13.2 ± 6.5% of surgeons per clinic were involved in robotic procedures. Defined operating room (OR) teams (82.4%) consisted of consultants, specialists and residents. Team training for surgeons and OR nurses was mainly (52.9%) based on clinic-specific programs. Due to the COVID-19 pandemic the number of robotic procedures decreased in 70.0% of the participating departments compared to 2019 with the highest decline reported during the second quarter of 2020 (64.7%). Referring to this, staff shortage of non-surgical disciplines (anesthesiologists 35.3%, OR nurses 35.3%, intensive care medics 17.6%), COVID-19-specific regulations (58.8%) and limited capacities of intensive and intermediate care (47.1%) were specified as underlying causes. Due to the COVID-19 pandemic, caused by a decline in numbers of robotic procedures, robotic training was paused completely in assistance at the operating table in 23.5% and at the second console in 42.9%. Conclusion: Robotic visceral surgery is already implemented with a broad spectrum of operations in many German clinics of different care levels; however, the relative proportion of robotic procedures is low, when compared to the overall caseload of each clinic. Training concepts are heterogeneous and focused on experts. In surgeons with growing experience in robotic surgery, conversion rates are recorded to be very low. There was a negative impact on robotic case numbers and training provided in 2020 caused by the COVID-19 pandemic. Therefore, a further endorsement of robotic training programs and an improvement of training designs seem to be essential tools in order to enforce robotic procedures in visceral surgery. [ABSTRACT FROM AUTHOR]

Background. Ongoing quantification of trends in high blood pressure and the consequent disease impact are crucial for monitoring and decision-making. This is particularly relevant in South Africa (SA) where hypertension is well-established. Objective. To quantify the burden of disease related to high systolic blood pressure (SBP) in SA for 2000, 2006 and 2012, and describe age, sex and population group differences. Methods. Using a comparative risk assessment methodology, the disease burden attributable to raised SBP was estimated according to age, se, and population group for adults aged ≥25 years in SA in the years 2000, 2006 and 2012. We conducted a meta-regression on data from nine national surveys (N=124 350) to estimate the mean and standard deviation of SBP for the selected years (1998 - 2017). Population attributable fractions were calculated from the estimated SBP distribution and relative risk, corrected for regression dilution bias for selected health outcomes associated with a raised SBP, above a theoretical minimum of 110 - 115 mmHg. The attributable burden was calculated based on the estimated total number of deaths and disability-adjusted life years (DALYs). Results. Mean SBP (mmHg) between 2000 and 2012 showed a slight increase for adults aged ≥25 years (127.3 - 128.3 for men; 124.5 - 125.2 for women), with a more noticeable increase in the prevalence of hypertension (31% - 39% in men; 34% - 40% in women). In both men and women, age-standardised rates (ASRs) for deaths and DALYs associated with raised SBP increased between 2000 and 2006 and then decreased in 2012. In 2000 and 2012, for men, the death ASR (339/100 000 v. 334/100 000) and DALYs (5 542/100 000 v. 5 423/100 000) were similar, whereas for women the death ASR decreased (318/100 000 v. 277/100 000) as did age-standardised DALYs (5 405/100 000 v. 4 778/100 000). In 2012, high SBP caused an estimated 62 314 deaths (95% uncertainty interval 62 519 - 63 608), accounting for 12.4% of all deaths. Stroke (haemorrhagic and ischaemic), hypertensive heart disease and ischaemic heart disease accounted for >80% of the disease burden attributable to raised SBP over the period. Conclusion. From 2000 to 2012, a stable mean SBP was found despite an increase in hypertension prevalence, ascribed to an improvement in the treatment of hypertension. Nevertheless, the high mortality burden attributable to high SBP underscores the need for improved care for hypertension and cardiovascular diseases, particularly stroke, to prevent morbidity and mortality.

Abstract Background Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. Methods This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. Results A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. Conclusions This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated.

Purpose: Bile duct injuries (BDI) during a laparoscopic cholecystectomy still remain as one of the most feared complications in surgery. The use of laparoscopy for its management is a controversial subject of discussion. The purpose of this study is to assess the amount of possibilities that a laparoscopic approach allows in its resolution. Methods: A retrospective analysis of all the patients diagnosed with BDI at our center was carried out. The analysis was made considering three different scenarios in which laparoscopy can be used: (1) intraoperative management of BDI; (2) postoperative management of bile peritonitis; (3) deferred treatment of BDI. Results: We analyzed 22 patients in total who were divided into three groups according to the different scenarios proposed. In the first group, the applicability of laparoscopy was 45%, some complications occurred in two patients, and primary patency was obtained in seven. In the second group, four of them presented a grade III complication. In the third group, the applicability of laparoscopy was 13.6%. Only one patient presented a IIIa complication and primary patency was obtained in all of them. Conclusions: Laparoscopy plays a more important role in BDI management every day. This approach, in selected cases, is associated with good long-term results and perioperative advantages of a minimally invasive approach. [ABSTRACT FROM AUTHOR]

Background: Biliary tree cysts (BTCs) represent an either localized or multifocal abnormal dilatation of the biliary tree, which entails an increased risk of acute cholangitis and cholangiocarcinoma (2.5%-16%). Its incidence in Western countries is ∼1/100.000-1/150.000, being more frequent in Asia (1/1.000). These cysts are usually classified according to Todani classification, which is based on site and morphology of cysts. Patients and Methods: This is a retrospective multicentric descriptive study of patients surgically treated for BTCs. From 2005 to 2018, 25 cases were collected between Hospital de la Santa Creu i Sant Pau (Barcelona, Spain) and Ospedale San Paolo (Savona, Italy). Clinical presentation was characterized by abdominal pain, jaundice, fever, and sometimes weight loss. Eight patients presented Todani type I, 1 patient Todani type II, 3 patients Todani III, 1 patient Todani type IV, and 12 patients Todani type V. Results: Among the 25 surgically treated patients, 12 patients underwent liver resection, 7 patients underwent resection of the extrahepatic biliary tree, 3 patients underwent BTC removal through a duodenotomy, 1 patient underwent resection of the extrahepatic biliary tree and liver resection, and 2 patients underwent pancreatoduodenectomy. Overall 30-day morbidity rate was 20%, and 90-day mortality was 0%. Pathologic examination confirmed diagnosis of cholangiocarcinoma in 5 patients (20%). After a median follow-up of 59 months, 20 patients are alive and in good conditions, whereas 50% of patients with cholangiocarcinoma died for disease progression. Conclusions: Surgical treatment for BTCs is associated with acceptable postoperative outcomes, with moderate morbidity and null mortality rates. Moreover, the risk of developing cholangiocarcinoma is still high that prompts surgical treatment once diagnosis is made. [ABSTRACT FROM AUTHOR]

The study aimed to assess temperature, histamine level and histamine producing bacteria (HPB) in four species of fresh fish samples i.e, Sardinellaaurita, Boopsboops, Trachurusmediterraneus and Scomberscombrus that are collected from three markets (A, B, C) within Tripoli city Libya. The results revealed that 95% of the fish samples had a temperature range between 5-22°C, while 5% had a temperature < 5° C. Histamine was recorded in 43% of the samples. The ranges of histamine in sardine, bouge, saury, and mackerel samples were 1.29-5.74; 1.34- 29.74;1.31-7.57 and 1.39-2.49 mg/100 g meat, respectively. These levels did not exceed the maximum limit (10 mg/100) adopted by the Libyan authority, except one sample (29.74 mg/100 g meat). A significant difference (P<0.05) in histamine levels was observed among the three markets. However, a nonsignificant difference (P>0.05) was observed between the fish species. The range for the means of HPBC in sardine, bouge, saury, and mackerel samples were 1.8x104-5.4x104; 6.4x104-2.0x105;6.4x104-6.9105; 1.6x104- 4.1x105cfu/g fish meat, respectively. Most of the HPB isolates were belonged to the family Enterobacteriaceae and some belong to the family Vibrionaceae. Vibrio fluvialis recorded the highest prevalence percentage (18%) followed by Erwiniaspp, S. putrrefacienes, and K. planticola, i.e.,12.2, 11.9 and 10.0%, respectively. The results of this study reflect the poor cooling conditions of the samples and poor cooling techniques practiced in these markets. Therefore, the hygienic practices in these markets have to be improved, and preferably the HACCP system has to be implemented. [ABSTRACT FROM AUTHOR]

Purpose: Globally planned surgical procedures have been deferred during the current COVID-19 pandemic. The study aimed to report the outcomes of planned urgent and cancer cases during the current pandemic using a multi-disciplinary prioritisation group. Methods: A prospective cohort study of patients having urgent or cancer surgery at a NHS Trust from 1st March to 30th April 2020 who had been prioritised by a multi-disciplinary COVID Surgery group. Rates of post-operative PCR positive and suspected COVID-19 infections within 30 days, 30-day mortality and any death related to COVID-19 are reported. Results: Overall 597 patients underwent surgery with a median age of 65 years (interquartile range (IQR) 54–74 years). Of these, 86.1% (514/597) had a current cancer diagnosis. During the period, 60.8% (363/597) of patients had surgery at the NHS Trust whilst 39.2% (234/597) had surgery at Independent Sector hospitals. The incidence of COVID-19 in the East Midlands was 193.7 per 100,000 population during the study period. In the 30 days following surgery, 1.3% (8/597) of patients tested positive for COVID-19 with all cases at the NHS site. Overall 30-day mortality was 0.7% (4/597). Following a PCR positive COVID-19 diagnosis, mortality was 25.0% (2/8). Including both PCR positive and suspected cases, 3.0% (18/597) developed COVID-19 infection with 1.3% at the independent site compared to 4.1% at the NHS Trust (p=0.047). Conclusions: Rates of COVID-19 infection in the post-operative period were low especially in the Independent Sector site. Mortality following a post-operative diagnosis of COVID-19 was high. [ABSTRACT FROM AUTHOR]

A avaliação do perfil bioquímico de proteínas do sêmen abriu novas fronteiras a partir da década de 90 na busca por marcadores associados ao potencial reprodutivo de touros. Esta revisão de literatura apresenta os fundamentos fisiológicos e bioquímicos básicos dos mecanismos de atuação das proteínas do sêmen e como afetam eficiência da criopreservação de gametas e fecundação em reprodutores bovinos. Apresentam-se os achados dos últimos 50 anos de pesquisas na área, bem quanto as atuais limitações, aplicações e perspectivas futuras, tanto para raças europeias, quanto zebuínas. Destaca-se o potencial como biomarcadores reprodutivos das chamadas proteínas ligadas aos espermatozoides (Binder of SPerm proteins - BSP), que se referem a um amplo grupo de proteínas que se ligam aos espermatozoides no momento da ejaculação, promovendo o início da capacitação, principalmente na presença de heparina. Também são descritos os resultados das principais pesquisas que buscaram pelas associações entre proteínas do sêmen com fertilidade e sucesso na criopreservação. Nas conclusões são apresentadas algumas das aplicações, impactos e perspectivas futuras para as pesquisas da área.

Background: The impact of epidural analgesia (EA) on postoperative morbidity and length of stay (LOS) after HPB surgery remains to be determined. These specific outcomes have been highlighted by the implementation of multiple enhanced recovery pathways (ERAS). The authors hypothesized that EA in the current environment may be associated with LOS and other outcomes. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) databases from 2014 to 2017 for patients undergoing open hepatopancreaticobiliary (HPB) surgery were included in a retrospective cohort analysis with propensity score matching (PSM) comparing EA with control. Results: Twenty-seven thousand two hundred eighteen patients underwent open HPB surgery, of which 6048 (22%) received EA. There was an increase use of EA over time (from 19.3 to 25.5%, p = 0.001). On PSM, EA was associated with more than half of a day increase in LOS for both pancreatic (p < 0.001) and hepatic surgery (p < 0.001). Furthermore, for pancreatic surgery, there was an increase in urinary tract infection (2.5% vs. 3.3%, p = 0.018), time to drain removal (7.8 vs. 8.7 days, p < 0.001), and discharge to rehabilitation (2.9% vs. 4.3%, p = 0.029). For hepatic surgery, there was an increase in blood transfusion requirements (17% vs. 20%, p = 0.019). There were no differences in overall morbidity and mortality. Conclusion: In this cohort of over 27,000 patients with granular surgical details, there was a significant increase in LOS associated with EA after HPB surgery, along with increased procedure-specific UTI and blood transfusion. With the ever-increasing need for standardized and efficient patient care pathways that reduce LOS, alternative analgesic adjuncts may be considered to optimize patient outcomes. [ABSTRACT FROM AUTHOR]

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Abstract Background How patients recover and resume everyday life after curative hepato-pancreato-biliary (HPB) surgery with intestinal reconstruction has, to our knowledge, not previously been investigated. We wanted to explore the patient experience in order to develop our capability to support their rehabilitation and identify interventional gaps in the current post-surgical care of these patients. Therefore, the aim of the present study was to explore patients’ experiences of their gut, digestion, recovery and uptake of everyday life after HPB surgery with intestinal reconstruction. Methods A qualitative explorative study with semi-structured interviews with 12 patients. We analysed data using qualitative content analysis with an inductive approach. Results Two main themes with six sub-themes emerged from the analysis: 1. “Disrupted gut” covering the sub-themes: the weakened body; fighting cachexia; re-aligning to the altered body. 2. “Recovery work” with the sub-themes: the value of municipal rehabilitation programmes; reclaiming the sociality of meals; going back to work. The patients described overarching digestive changes, predominantly diarrhea and nausea. Diarrhea and nausea challenged rehabilitation efforts and limited patients’ participation in social activities. Patients toiled to regain strength and every-day life as it was before surgery. Current municipal rehabilitation programmes facilitated these efforts. Conclusions The patients articulated an overarching experience of gut disruption, predominantly presenting as nausea, diarrhea and difficulty eating. This challenged their recovery work and uptake of every-day life. Specialised follow-up at expert centres might mitigate the sequelae of gut disruption after HPB surgery. We suggest that follow-up programmes systematically monitor the experienced symptoms of gut disruption with HPB-specific PROMS. Furthermore, research into the pathophysiology of cachexia and novel interventions for reducing cachexia and weakness after curative HPB surgery is relevant.

Split hopkinson pressure bar (SHPB) was used to test the dynamic property of sandstone under different impact speeds and wavelengths.The results showed that for the same length of impact wave，the greater of the impact velocity could result in the greater the stress amplitude of the incident wave，transmission wave and reflect wave.Under the same impact velocity，the amplitudes of incident wave was approximately the same，and the amplitude of the reflected wave and transmitted wave increases with increasing of the wavelength. The stress amplitude and strain rate are linearly dependent on the dynamic peak strength.The magnitude of the stress amplitude and the maximum strain of the sandstone are exponentially related.Stress wave length and stress amplitude are the main factors affecting the damage of sandstone.Basing on the proposing research，a damage model of sandstone is proposed.The error of the sandshoe damage calculated by this formula is in a reasonable range.

Introduction: Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined.Methods: Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined.Results: Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001).Conclusion: Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care. [ABSTRACT FROM AUTHOR]

Background: Pre-operative anemia is a common, but treatable, condition encountered by surgical patients. It has been associated with increased perioperative complications, length of stay, and blood transfusions. The aim of this project was to increase the treatment rate of pre-operative anemia to 75% of patients consented for major hepato-pancreato-biliary (HPB) surgery. Methods: This was an interrupted time series study and a spread initiative from a similar project in a colorectal surgery population. Interventions included an anemia screening and treatment algorithm, standardized blood work, referral to a patient blood management program, and standardized oral iron prescriptions. The primary outcome measure was the change in pre-operative anemia treatment rate and the secondary outcome measure was the post treatment increase in hemoglobin. Results: A total of 208 patients were included (n = 124 pre-intervention and n = 84 post-intervention). Anemia was present in 39.9% of patients. The treatment rate of pre-operative anemia increased to 44.1% from 28.6%. The mean hemoglobin increased from 110 g/L to 119 g/L in patients who were treated (p = 0.03). There was no significant increase or decrease in blood transfusions or mean number of red cell units transfused per patient. Screening rates for pre-operative anemia increased from 41.1 to 64.3% and appropriate referrals to the patient blood management program increased from 14.3 to 67.6%. Conclusions: This study demonstrates a small scale spread initiative focused on the treatment of pre-operative anemia. Although the goal to treat 75% of anemic patients was not reached, an effective referral pathway to an existing patient blood management program was developed, and a significant increase in the mean hemoglobin in anemic patients who have been treated pre-operatively was demonstrated. [ABSTRACT FROM AUTHOR]

Anthropometric parameters have been associated with increased risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Nonetheless, conventional metrics to predict POPF do not include the assessment of body composition. We aimed to validate the most used Fistula Risk Score (FRS), and to assess whether the appraisal of adipose compartment at bioimpedance vector analysis (BIVA) improves the accuracy of FRS in CR-POPF prediction. PD patients from 3 Italian academic institutions were prospectively included over a 2-year period. Patients with ASA score ≥3, heart failure, chronic kidney disease, or compartmentalized fluid collections were excluded. BIVA was performed on the day prior to surgery. CR-POPF occurrence and severity were classified per the ISGPS classification. Out of 148 PDs, 84 patients (56.8%) had pancreatic cancer, and 29 (19.6%) experienced CR-POPF. FRS elements, namely soft pancreatic texture (p = 0.009), small pancreatic duct diameter (p = 0.029), but not blood loss (p = 0.450), as well as high BMI (p = 0.004) were associated with CR-POPF. Also, the preoperative fat mass (FM) amount measured at BIVA was significantly higher in patients who developed CR-POPF, compared to those who did not (median FM = 19.4 kg/m2 vs. 14.4 kg/m2, respectively; p = 0.005). The predictive ability of a multivariate model adding FM to the FRS, assessed at the receiver operating characteristics curve showed a higher accuracy than the FRS alone (AUC = 0.774 and AUC = 0.738, respectively). Assessment of preoperative FM at BIVA can improve the accuracy of FRS in predicting CR-POPF following pancreatoduodenectomy. [ABSTRACT FROM AUTHOR]

4-(Methylnitrosamino)-l-(3-pyridyl)-1-butanone (NNK) and N -nitrosonornicotine (NNN), two tobacco specific nitrosamine carcinogens, can form adducts with DNA and proteins via pyridyloxobutylation upon phase I enzyme-mediated bioactivation. Such DNA modifications have been proposed as the root cause to initiate carcinogenesis. Upon hydrolysis, both DNA and protein modifications would release 4-hydroxy-1-(3-pyridyl)-1-butanone (HPB). The released HPB, being tobacco carcinogen specific, has the potential to serve as a surrogate biomarker for both tobacco exposure and carcinogen bioactivation. Because of its easy access, blood is a great source of such investigations with the potential in epidemiological application. HPB quantification from haemoglobin (Hb), however, has been demonstrated with limited success. To further explore this potentially paradigm-shift opportunity, we reported, for the first time, the detection and quantification of HPB from albumin (Alb) adducts formed by the tobacco-specific nitrosamines in mice and in human smokers. The time-course quantitative analysis of HPB from mouse Alb upon NNK exposure suggests that such an Alb adduct is stable. The amounts of HPB from Alb adducts in smoker plasma averaged 1.82 ± 0.19 pg/mg Alb (0.42 to 3.11 pg/mg Alb), which was 36 times the value in nonsmokers (0.05 ± 0.01 pg/mg Alb). Importantly, HPB level from Alb correlated positively with the level of human tobacco exposure estimated by urinary total nicotine equivalent (TNE) (R2 = 0.6170). For comparison, HPB level from Alb was 16.5 times that of Hb (0.12 ± 0.02 pg/mg Hb) in the plasma and red blood cell (RBC) samples of the same smokers. In addition, there was no significant correlation between HPB levels from Hb and TNE (R2 = 0.0719). These data overall suggest that HPB from Alb adducts can serve as a surrogate biomarker to monitor the level of tobacco exposure and carcinogenic nitrosamine bioactivation. [ABSTRACT FROM AUTHOR]

Introduction: Early readmissions (30 days) have been used as a measure of health care quality. The purpose of our study was to evaluate patterns of readmission for a longer period (up to 2 years) following Hepatopancreatobiliary (HPB) surgery in the state of New York.Methods: The State Planning and Research Cooperative System database was utilized to identify patients undergoing complex HPB procedures between 2010 and 2012. Patients were followed for 2 years following surgery to identify all-cause readmissions. Factors for readmissions included patient demographics, comorbidities, perioperative complications, surgery type, and academic status. Multivariable generalized linear mixed models were performed to evaluate risk factors for readmissions.Results: There were 6207 complex HPB procedures with 1272 (20.49%) unplanned 30-day readmissions, 816 (13.15%) unplanned 31-90-day readmissions, 1678 (27.03%) unplanned 91-day to 1-year readmissions, and 1404 (22.62%) 1-2-year readmissions. After adjusting for other possible confounding factors, risk factors for 30-day readmissions include surgery type, as pancreatectomy and gallbladder patients are more likely to have a 30-day readmission than hepatectomy patients, facility type, as academic centers are more likely to have a readmission, male gender, presence of any comorbidity, and peri-operative complications. Risk factors for 31-90-day readmissions include race, insurance group, any comorbidity or any peri-operative complication, and 30-day readmissions. Risk factors for 91-day to 1-year readmissions include male gender, race, any comorbidity, 30-day readmissions, and 31-90 days' readmissions. Risk factors for 1-2-year readmissions include presence of any comorbidity, and previous 91-day to 1-year readmissions.Conclusion: The 30-day readmission window is an inadequate, but predictive, measure of total readmission following complex HPB procedures. [ABSTRACT FROM AUTHOR]

A fisiopatologia da hiperplasia prostática benigna (HPB) não está totalmente compreendida, no entanto, a diidrotestosterona é o principal hormônio envolvido. Recentemente, o efeito da toxina botulínica A (TB-A) foi investigado, mostrando que esta induz atrofia do parênquima e redução do volume prostático. Com base nisso, este estudo teve como objetivos comparar os efeitos da administração da TB-A com a orquiectomia no tratamento da HPB, além de avaliar os efeitos da TB-A sobre a libido e qualidade do sêmen. Para tanto, 16 cães adultos foram submetidos à castração ou administração de 500U de TB-A, e avaliados durante 16 semanas. A orquiectomia mostrou-se um excelente tratamento, promovendo redução de 80% do volume prostático. Aplicação da TB-A não ocasionou alterações na libido, ereção ou qualidade e características seminais. Por outro lado, reduziu significamente o volume da próstata. Os resultados sugerem que a administração intraprostática de TB-A é um tratamento alternativo efetivo e sem efeitos colaterais para cães destinados a programas de reprodução. No entanto, esta terapia apresenta reduções inferiores do volume prostático, quando comparada com a orquiectomia.

Background: How patients recover and resume everyday life after curative hepato-pancreato-biliary (HPB) surgery with intestinal reconstruction has, to our knowledge, not previously been investigated. We wanted to explore the patient experience in order to develop our capability to support their rehabilitation and identify interventional gaps in the current post-surgical care of these patients. Therefore, the aim of the present study was to explore patients' experiences of their gut, digestion, recovery and uptake of everyday life after HPB surgery with intestinal reconstruction.Methods: A qualitative explorative study with semi-structured interviews with 12 patients. We analysed data using qualitative content analysis with an inductive approach.Results: Two main themes with six sub-themes emerged from the analysis: 1. "Disrupted gut" covering the sub-themes: the weakened body; fighting cachexia; re-aligning to the altered body. 2. "Recovery work" with the sub-themes: the value of municipal rehabilitation programmes; reclaiming the sociality of meals; going back to work. The patients described overarching digestive changes, predominantly diarrhea and nausea. Diarrhea and nausea challenged rehabilitation efforts and limited patients' participation in social activities. Patients toiled to regain strength and every-day life as it was before surgery. Current municipal rehabilitation programmes facilitated these efforts.Conclusions: The patients articulated an overarching experience of gut disruption, predominantly presenting as nausea, diarrhea and difficulty eating. This challenged their recovery work and uptake of every-day life. Specialised follow-up at expert centres might mitigate the sequelae of gut disruption after HPB surgery. We suggest that follow-up programmes systematically monitor the experienced symptoms of gut disruption with HPB-specific PROMS. Furthermore, research into the pathophysiology of cachexia and novel interventions for reducing cachexia and weakness after curative HPB surgery is relevant. [ABSTRACT FROM AUTHOR]

As doenças prostáticas são comuns em cães, desenvolvendo-se após a maturidade sexual. Entre as afecções que acometem a próstata desses animais, a mais frequente é a hiperplasia prostática benigna (HPB). As neoplasias prostáticas, apesar de menos frequentes, são altamente malignas e um diagnóstico tardio está associado a um prognóstico ruim. Os principais métodos de diagnóstico das enfermidades prostáticas em cães incluem um exame clínico detalhado, ultrassonografia, punção aspirativa e biópsia. A utilização de biomarcadores séricos vem sendo estudada como uma maneira de se detectar a doença precocemente, evitando possíveis complicações no quadro clínico dos pacientes. Assim, estudos visando ao diagnóstico precoce de prostatopatias caninas, especialmente o câncer prostático, são cruciais para um tratamento eficaz e melhora da qualidade de vida do animal acometido.Prostatic diseases are common in older dogs, developing after sexual maturity. The most common affecting canine prostate is benign prostatic hyperplasia (BPH). Although less frequent, prostatic neoplasias are highly malignant, and a late diagnosis is closely associated with a poor prognosis. The main methods of diagnosis of the canine prostatic disease include a detailed clinical exam, ultrasound, prostatic fine-needle aspirate and biopsy. Studies towards early diagnosis of this condition are crucial for effective treatment and improvement of quality of life of affected animals. The use of biomarkers has been studied for early detection of the disease, avoiding possible complications in clinical patients.

This research examines the Health Promotion Behavior (HPB) models regarding elderly pedestrians’ behaviors and attitudes. We studied cognitive-psychological variables, such as risk estimation, self-efficacy and demographic variables and compared elderly pedestrians’ attitudes and behaviors in a city with higher socio-economic level (Tel Aviv) versus a city with low socio-economic level (Beer Sheva). We expected to find more problematic behaviors among elderly pedestrians in the low socio-economic city compared to the high socio-economic city, and also less feeling of self-efficacy, and lessened awareness of the risks, that leads to lessened willingness to adopt preventive behaviors. The research was conducted in two studies. The first study was based on observations on 2591 pedestrians in six similar crosswalks in both cities. It revealed that pedestrians in the high socio-economic city demonstrated safer road crossing patterns than in the low socio-economic city and that elderly pedestrians reveal safer crossing patterns than younger pedestrians. We found an interaction of location and age due to greater gap of safe behaviors of elderly and young pedestrians in the high socio-economic city than in the low socio-economic city. In Tel Aviv elderly adhere to the crossing rules much more than the young while in Beer Sheva elderly and young people are almost similar in their crossing patterns. The second study used questionnaires that have been completed by 143 elderly in both cities. The questionnaires referred to (a) demographic variables such as gender, age, marital status, education, socio-economic level, (b) variables related to the affiliation to the main culture such as migration, date of migration, knowledge in Hebrew (local language) and connectivity to media and (c) cognitive as well as psychological variables related to the decline to adopt healthy behaviors based on Schwarzer and Fuchs (1995) . This part also indicated that elderly in Tel Aviv have higher awareness of risk factors on the road and their limitations as elderly pedestrians. The HPB ( Pender, 1996 ) emphasizes the role of risk perception as a predictor of willingness to adopt preventive strategies. Moreover, elderly pedestrians in Beer Sheva compared to those in Tel Aviv estimated their ability to cross safely the streets as higher. [ABSTRACT FROM AUTHOR]