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Background Recruitment into surgical RCTs can be threatened if new interventions available outside the trial compete with those being evaluated. Adapting the trial to include the new intervention may overcome this issue, yet this is not often done in surgery. This paper describes the challenges, rationale and methods for adapting an RCT to include a new intervention. Methods The By-Band study was designed in the UK in 2009-2010 to compare the effectiveness of laparoscopic adjustable gastric band and Roux-en- Y gastric bypass for severe obesity. It contained a pilot phase to establish whether recruitment was possible, and the grant proposal specified that an adaptation to include sleeve gastrectomy would be considered if practice changed and recruitment was successful. Information on changing obesity surgery practice, updated evidence and expert opinion about trial design were used to inform the adaptation. Results The pilot phase recruited over 13 months in 2013-2014 and randomized 80 patients (79 anticipated). During this time, major changes in obesity practice in the UK were observed, with gastric band reducing from 32·6 to 15·8 per cent and sleeve gastrectomy increasing from 9·0 to 28·1 per cent. The evidence base had not changed markedly. The British Obesity and Metabolic Surgery Society and study oversight committees supported an adaptation to include sleeve gastrectomy, and a proposal to do so was approved by the funder. Conclusion Adaptation of a two-group surgical RCT can allow evaluation of a third procedure and maintain relevance of the RCT to practice. It also optimizes the use of existing trial infrastructure to answer an additional important research question. Registration number: ISRCTN00786323 (/). [ABSTRACT FROM AUTHOR]

Background: The maternal mortality rate in Libya surpasses the regional average and is primarily due to sepsis, hemorrhages, hypertension, and other factors, highlighting gaps in maternal knowledge and access to quality care. This study aimed to assess the awareness of obstetric danger signs and associated factors among pregnant women attending the outpatient clinic of Tobruk Medical Center, Libya., Methods: An institution-based cross-sectional study was conducted from August to October 2023, involving 301 pregnant women visiting the outpatient clinic. Convenience sampling was utilized, and data were collected using structured questionnaires. Data were initially stored in Excel and then imported into R (version 4.3.1) for analysis. Descriptive statistics were applied to both categorical and continuous variables. Logistic regression was used to study the association between awareness of danger signs and socio-demographic variables, with p-values calculated and multivariate analysis performed to adjust for confounding factors., Results: Results revealed that 239 (79.4%) pregnant women were aware of danger signs. Additionally, the most cited danger signs were "fatigue" (41.5%) and "severe headache" (23.3%), whereas the least common was "sudden gush of fluids" (10.6%). Marital status was found to be an independent predictor of knowledge about pregnancy danger signs, whereby married women were more likely to have awareness than divorced women (AOR:0.16, CI: 0.04-0.71, P-value: 0.016)., Conclusion: To improve maternal healthcare, ANC units should focus on educating patients about under-recognized signs and encourage peer discussions through social media. These steps aim to enhance preparedness and reduce pregnancy-related complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Linkage studies have indicated a potential genetic predisposition to cholelithiasis. This study aims to determine the frequency of positive family history of gallstone disease in patients presenting with gallstones in a Pakistani population. A descriptive, cross-sectional study was conducted at the surgical department of the University of Lahore Teaching Hospital from June 30, 2023 to August 30, 2023. A total of 102 radiologically confirmed cholelithiasis patients were enrolled. Out of 102 participants, 75.5% (n = 77) were females, with a mean age at presentation of 42.1 ± 12.1 years. The study found that 32.4% (n = 33) of participants had a single family member with gallstones, 3.9% (n = 4) had 2 family members affected, and 1% (n = 1) had 3 family members affected. The attributable risk of genetics from our study was 37.2%. Additionally, there was no significant association between positive family history and earlier onset of disease. A significant percentage of Pakistani population may have gallstone disease due to genetic factors., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: In kidney transplant (KT) surgery, the perioperative administration of intravenous (IV) fluids plays a crucial role, with potential effects on graft function. Our meta-analysis aims to assess the post-KT outcomes of perioperative balanced crystalloids (BC) versus normal saline (NS)., Methods: We conducted a comprehensive search across five databases to identify relevant randomized controlled trials (RCTs). The search results were imported into Covidence for article eligibility screening, and all relevant outcome data were synthesized using risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CIs) in meta-analysis models within RevMan 5.4., Prospero Id: CRD42023448457., Results: Pooled data from 15 RCTs with 2,008 participants showed that the rate of delayed graft function (DGF) was significantly lower with BC (RR: 0.78, 95% CI [0.68, 0.91], P = 0.0009). Also, BC was associated with significantly higher post-op blood pH (MD: 0.05, 95% CI [0.03, 0.07], P < 0.01), lower serum chloride (MD: - 7.31, 95% CI [- 10.58, - 3.77], P < 0.01), and sodium (MD: - 1.94, 95% CI [- 3.32, - 0.55], P = 0.006) as compared to NS. However, serum potassium, serum creatinine, and urine output at POD 1 to 7 did not differ between the two groups., Conclusion: BC significantly reduced the incidence of DGF, resulting in more stable post-operative acid-base parameters, and lower chloride levels compared to NS. Hence, substituting NS with BC offers a strategy to protect grafts from acidotic and hyperchloremic insults, optimizing KT outcomes., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Key Clinical Message: Podiatrists and orthopedists should be vigilant for chronically evolving, hyperalgic soft lumps in the foot with vascular radiological features, prompting early detection of glomus tumor, timely mass removal, providing pain relief and improving patient's quality of life., Abstract: Glomus tumors refers to a rare group of benign perivascular neoplasms that originate from a neuromyoarterial structure called a glomus body. These tumors are characterized by their painful nature and predominant distribution in the extremities mainly the fingers, the hands and the feet. Nonetheless, the diagnosis is usually made after several years of symptoms experience as the lesions are mostly small, not palpable, and have variable presentations. Radiological workup especially with magnetic resonance imaging is very useful for diagnosing the tumoral process, however, confirmation can only be obtained by histological analysis. The treatment is purely surgical, and it is successful in most cases. Herein, we describe a case of glomus tumor of the foot dorsal side among a middle age male patient., Competing Interests: None., (© 2024 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.)

Background: Evidence regarding the type and rate of intravenous (IV) fluid administration during labor is still inconclusive and the studies assessing the impact of IV fluids had mixed results., Objectives: To evaluate the effects of IV fluids at an infusion rate of 250 mL/h as compared with 125 mL/h on labor outcomes in nulliparous women., Search Strategy: We searched six databases for relevant studies through a search strategy containing the relevant keywords "IV hydration", "IV fluids", and "labor" from the inception of these databases to May 1, 2023, without any applied restrictions., Selection Criteria: Search results were imported to Covidence for screening of eligible articles for this review. Randomized controlled trials (RCTs) assessing the impact of IV fluids at 250 mL/h on the outcomes of labor in nulliparous women at term (>37 weeks) as compared with 125 mL/h were included only., Data Collection and Analysis: Data regarding the characteristics of included studies, participant's baseline characteristics, and concerned outcomes were collected in an Excel spreadsheet and all the concerned outcomes were pooled as risk ratios (RR) or mean difference (MD) with 95% confidence interval (CI) in the meta-analysis models using RevMan 5.4., Main Results: Pooled data from 11 RCTs with 1815 patients showed that 250 mL/h infusion rate had a significant reduction in cesarean section rate (RR 0.70, 95% CI 0.56-0.88, P = 0.002), the first stage of labor duration (MD -46.97, 95% CI -81.79 to -12.14, P = 0.008), the second stage of labor duration (MD -2.69, 95% CI -4.34 to -1.05, P = 0.001), prolonged labor incidence (RR 0.72, 95% CI 0.58-0.89, P = 0.003), as compared with 125 mL/h. Also, the vaginal delivery rate (RR 1.07, 95% CI 1.02-1.12, P = 0.009) was higher with a 250 mL/h infusion rate., Conclusion: IV fluids at an infusion rate of 250 mL/h during labor in nulliparous women decreased the cesarean delivery rate, increased the vaginal delivery rate, shortened the first and second-stage labor duration, decreased the incidence of prolonged labor as compared with 125 mL/h. These findings suggest enhanced labor progression and a lower risk of labor complications with higher infusion rates. However, future research involving a more diverse population and exploring the potential benefits of combining IV infusion rates with other interventions, such as adding dextrose or less restrictive oral intake during labor, is needed., (© 2023 International Federation of Gynecology and Obstetrics.)

Alzheimer disease (AD) is a devastating neurodegenerative disorder that affects millions of individuals worldwide, with no effective cure. The main symptoms include learning and memory loss, and the inability to carry out the simplest tasks, significantly affecting patients' quality of life. Over the past few years, tremendous progress has been made in research demonstrating a link between AD and major depressive disorder (MDD). Evidence suggests that MDD is commonly associated with AD and that it can serve as a precipitating factor for this disease. Antidepressants such as selective serotonin reuptake inhibitors, which are the first line of treatment for MDD, have shown great promise in the treatment of depression in AD, although their effectiveness remains controversial. The goal of this review is to summarize current knowledge regarding the association between AD, MDD, and antidepressant treatment. It first provides an overview of the interaction between AD and MDD at the level of genes, brain regions, neurotransmitter systems, and neuroinflammatory markers. The review then presents current evidence regarding the effectiveness of various antidepressants for AD-related pathophysiology and then finally discusses current limitations, challenges, and future directions., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lateral internal sphincterotomy (LIS) has been the gold standard for treating chronic anal fissure (CAF) that persists despite other measures. The authors aim to evaluate the effects of the close method (CLIS) of performing LIS as compared to the open method (OLIS)., Methods: Databases were searched for relevant studies and results were screened to identify eligible articles, and all concerned outcomes were pooled as odd ratio (OR) or mean difference (MD) with 95% CI in the meta-analysis models using RevMan 5.4., Results: Pooled data from 16 trials with 1,711 patients with idiopathic CAF showed that the CLIS has significant lower risk of delayed fissure healing [OR: 0.28, 95% CI (0.10, 0.77), P = 0.01], duration of hospital stay [MD: -0.82 with 95% CI (-1.07, -0.57), P < 0.00001] and postoperative visual analogue pain score (VAPS) at 24 h [MD: -0.30 with 95% CI (-0.39, -0.21), P < 0.00001]. Also, the risk of overall complications [OR: 0.33 with 95% CI (0.19, 0.55), P < 0.0001], incontinence [OR: 0.28 with 95% CI (0.20, 0.38), P < 0.00001], and postoperative pain [OR: 0.56 with 95% CI (0.35, 0.91), P = 0.02] was significantly lower with CLIS., Conclusion: CLIS is a safer option than OLIS for treating anal fissure. The risk of delayed fissure healing, incontinence, post-op pain and overall complication was significantly lower. However, the risk of surgical site infection, postoperative bleeding and recurrence did not differ. Future research with more prolonged follow-up is necessary to document recurrence reliably., Competing Interests: The author declared no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Metabolic surgery leads to weight loss and improved health, but these outcomes are highly variable. Poor weight loss is associated with lower circulating levels of glucagon-like peptide-1 (GLP-1)., Objective: To assess the efficacy and safety of the GLP-1 receptor agonist, liraglutide, 3.0 mg, on percentage body weight reduction in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery., Design, Setting, and Participants: The Evaluation of Liraglutide 3.0 mg in Patients With Poor Weight Loss and a Suboptimal Glucagon-Like Peptide-1 Response (BARI-OPTIMISE) randomized placebo-controlled trial recruited adult patients at least 1 year after metabolic surgery who had experienced 20% or less body weight loss from the day of surgery and a suboptimal nutrient-stimulated GLP-1 response from 2 hospitals in London, United Kingdom, between October 2018 and November 2019. Key exclusion criteria were type 1 diabetes; severe concomitant psychiatric, gastrointestinal, cardiac, kidney or metabolic disease; and use of insulin, GLP-1 receptor analogues, and medication that can affect weight. The study period was 24 weeks followed by a 4-week follow-up period. Last participant follow-up was completed in June 2020. All participants and clinical study personnel were blinded to treatment allocation. Of 154 assessed for eligibility, 70 met trial criteria and were included in the study, and 57 completed follow-up., Interventions: Liraglutide, 3.0 mg, once daily or placebo as an adjunct to lifestyle intervention with a 500-kcal daily energy deficit for 24 weeks, on a 1:1 allocation by computer-generated randomization sequence, stratified by surgery type (Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and type 2 diabetes status., Main Outcome and Measures: The primary outcome was change in percentage body weight from baseline to the end of the 24-week study period based on an intention-to-treat analysis. Participant safety was assessed through monitoring of biochemical parameters, including kidney and liver function, physical examination, and assessment for adverse events., Results: A total of 70 participants (mean [SD] age, 47.6 [10.7] years; 52 [74%] female) with a poor weight loss response following RYGB or SG were randomized to receive 3.0-mg liraglutide (n = 35) or placebo (n = 35). All participants received at least 1 dose of the trial drug. Eight participants discontinued treatment (4 per group), and 2 in the 3.0-mg liraglutide group and 1 in the placebo group were lost to follow-up. Due to COVID-19 restrictions, 3 participants in the 3.0-mg liraglutide group and 7 in the placebo group were unable to attend their final in-person assessment. Estimated change in mean (SD) percentage body weight from baseline to week 24 was -8.82 (4.94) with liraglutide, 3.0 mg (n = 31), vs -0.54 (3.32) with placebo (n = 26). The mean difference in percentage body weight change for liraglutide, 3.0 mg, vs placebo was -8.03 (95% CI, -10.39 to -5.66; P < .001). Adverse events, predominantly gastrointestinal, were more frequent with liraglutide, 3.0 mg (28 events [80%]), than placebo (20 events [57%]). There were no serious adverse events and no treatment-related deaths., Conclusion and Relevance: These findings support the use of adjuvant liraglutide, 3.0 mg, for weight management in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery., Trial Registration: ClinicalTrials.gov Identifier: NCT03341429.

The desire for longevity, beauty, and health is as old as the history of human culture. Minimizing tissue damage and invasive surgeries has led to a variety of options in the 21 st century medicine. In the past 20 years, hyaluronic acid filler injections have thus become a popular modality of treatment for facial rejuvenation due to low costs for patients with immediately visible results. Ideally, the treated face looks natural. We aim at stopping time, maybe tweaking the handles of our clocks a bit backward to counteract aging processes, but creating a natural look and maintaining the individual appearance., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The novel coronavirus (COVID-19) pandemic is expected to last for an extended time, making strict safety precautions for office procedures unavoidable. The lockdown is going to be lifted in many areas, and strict guidelines detailing the infection control measures for aesthetic clinics are going to be of particular importance., Methods: A virtual meeting was conducted with the members (n = 12) of the European Academy of Facial Plastic Surgery Focus Group to outline the safety protocol for the nonsurgical facial aesthetic procedures for aesthetic practices in order to protect the clinic staff and the patients from SARS-CoV-2 infection. The data analysis was undertaken by thematic and iterative approach., Results: Consensus guidelines for nonsurgical facial aesthetic procedures based on current knowledge are provided for three levels: precautions before visiting the clinic, precautions during the clinic visit, and precautions after the clinic visit., Conclusions: Sound infection control measures are mandatory for nonsurgical aesthetic practices all around the world. These may vary from country to country, but this logical approach can be customized according to the respective country laws and guidelines., (© 2020 Wiley Periodicals, LLC.)

Background: Stauffer Syndrome (SS) is a paraneoplastic disorder associated with renal cell carcinoma (RCC). First described by Herbert Maurice Stauffer in 1961, it is characterized by hepatic dysfunction in the absence of metastasis, and elevated alkaline phosphatase, aminotransferases and prolonged prothrombin time. Initial reports did not include jaundice as an inclusion criterion. We aim to report the rare SS jaundice variant in a patient with a small renal mass and review the literature to determine if the size of the renal mass could influence the development of the SS., Case Presentation: The aim of this article is to present the case of a 53-year-old male with Stauffer syndrome jaundice variant secondary to a 2.5 cm renal mass, treated with laparoscopic radical nephrectomy with complete resolution of the syndrome., Conclusions: This syndrome is yet to be fully understood, and as far as the evidence shows, size does not matter. This entity should always be in mind when encountered with a patient with liver dysfunction and jaundice with a suspicion or confirmed diagnosis of a renal mass. To date, and to our knowledge, there have been eleven reported cases of paraneoplastic cholestatic jaundice syndrome including the current case. Six cases presented in patients with small renal mases (< 4 cm), curiously there were not a laterality tendency.

Kelley-Seegmiller syndrome (KSS) is a disorder that occurs when there is a partial deficiency of the enzyme hypoxanthine guanine phosphoribosyl transferase. It is involved in the metabolism of purines, clinically manifesting as hyperuricemia, hyperuricosuria, gout arthritis, and urolithiasis. The aim of this article is to present the case of a 33-year-old male with KSS, with left ureteral colic, and a 5-mm, 323-HU ureteral calculi, successfully managed with conservative management. It is critical to recognize that most urologists are not familiar with this inborn metabolic error and 75% of these patients will be affected by urolithiasis, thus making it a very critical and significant disease in our practice., (© 2018 S. Karger AG, Basel.)

Background: Diverticular disease of the appendix is an uncommon condition, with an incidence from 0.004 to 2.1%. It usually occurs between the fourth or fifth decades of life, does not present gastrointestinal symptoms but only insidious abdominal pain. Patients usually delay consultation, leading to increased morbidity and mortality. The aim of this study was to determine the clinical features of diverticular disease of the appendix., Methods: A retrospective study of all patients undergoing appendectomy in a tertiary hospital between September 2003 and September 2013 was performed., Results: During this period, 7,044 appendectomies were performed, and 42 cases of diverticular disease of the appendix were found, which represents an incidence of 0.59%. A total of 27 patients were male. The mean age was 46.6±21 years. The average hospital stay was 4.5 days. A perforated appendix was identified in 46% of patients. In 80% of the cases, a complementary imaging test was performed. The incidence of neoplastic disease with diverticulum of the appendix was 7.1%., Conclusions: Diverticular disease of the appendix is an incidental finding. In its acute phase, it presents as an acute appendicitis. The treatment of choice is appendectomy. It presents a higher risk of developing neoplastic disease of the appendix., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)