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BACKGROUND: Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. RESULTS: A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. CONCLUSION: This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

BACKGROUND: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patients directives, family feelings and representatives desires, and all decisions should be shared. CONCLUSIONS: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.

First-year medical students are often challenged by the rapid pace and large volume of content that must be learned. Peer teaching has emerged as a supportive educational strategy. However, the most effective strategies for training peer tutors (PTs) for their role are not known. This paper examines the use of an Objective Structured Teaching Exercise (OSTE) to augment PT training sessions. Applying deliberate practice as a conceptual framework, an OSTE was used to provide tutors with an opportunity to practice their skills and receive feedback about their performance when meeting with a student presenting with a challenge. The newly trained PTs were required to assess a standardized student, determine challenge(s) being experienced, and present options to address the challenge(s). Standardized students evaluated the tutors' performance and a pre- and post-OSTE questionnaire was used to determine whether the OSTE was effective in increasing the confidence level of PTs to effectively assess and support students seeking help. Participants reported an increase in confidence in their ability to assess areas requiring improvement, understand the active learning strategies, and suggest appropriate active learning study strategies. Evaluations completed by standardized students documented that newly trained PTs accurately diagnosed the challenge presented in the OSTE and in most cases PTs asked all relevant questions to assess. Increased self-efficacy promotes PT's capacity to perform their work and feedback during an OSTE can further advance required skills. Aggregate OSTE results can also inform efforts to enhance the PT training program.

Abstract Background The quality of Big Data analysis in medicine and surgery heavily depends on the methods used for clinical data collection, organization, and storage. The Knowledge Graph (KG) represents knowledge through a semantic model, enhancing connections between diverse and complex information. While it can improve the quality of health data collection, it has limitations that can be addressed by the Decentralized (blockchain-powered) Knowledge Graph (DKG). We report our experience in developing a DKG to organize data and knowledge in the field of emergency surgery. Methods and results The authors leveraged the cyb.ai protocol, a decentralized protocol within the Cosmos network, to develop the Emergency Surgery DKG. They populated the DKG with relevant information using publications from the World Society of Emergency Surgery (WSES) featured in the World Journal of Emergency Surgery (WJES). The result was the Decentralized Knowledge Graph (DKG) for the WSES-WJES bibliography. Conclusions Utilizing a DKG enables more effective structuring and organization of medical knowledge. This facilitates a deeper understanding of the interrelationships between various aspects of medicine and surgery, ultimately enhancing the diagnosis and treatment of different diseases. The system’s design aims to be inclusive and user-friendly, providing access to high-quality surgical knowledge for healthcare providers worldwide, regardless of their technological capabilities or geographical location. As the DKG evolves, ongoing attention to user feedback, regulatory frameworks, and ethical considerations will be critical to its long-term success and global impact in the surgical field.

Abstract Background Rib fractures are one of the most common traumatic injuries and may result in significant morbidity and mortality. Despite growing evidence, technological advances and increasing acceptance, surgical stabilization of rib fractures (SSRF) remains not uniformly considered in trauma centers. Indications, contraindications, appropriate timing, surgical approaches and utilized implants are part of an ongoing debate. The present position paper, which is endorsed by the World Society of Emergency Surgery (WSES), and supported by the Chest Wall Injury Society, aims to provide a review of the literature investigating the use of SSRF in rib fracture management to develop graded position statements, providing an updated guide and reference for SSRF. Methods This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of experts then critically revised the manuscript and discussed it in detail, to develop a consensus on the position statements. Results A total of 287 studies (systematic reviews, randomized clinical trial, prospective and retrospective comparative studies, case series, original articles) have been selected from an initial pool of 9928 studies. Thirty-nine graded position statements were put forward to address eight crucial aspects of SSRF: surgical indications, contraindications, optimal timing of surgery, preoperative imaging evaluation, rib fracture sites for surgical fixation, management of concurrent thoracic injuries, surgical approach, stabilization methods and material selection. Conclusion This consensus document addresses the key focus questions on surgical treatment of rib fractures. The expert recommendations clarify current evidences on SSRF indications, timing, operative planning, approaches and techniques, with the aim to guide clinicians in optimizing the management of rib fractures, to improve patient outcomes and direct future research.

The aim of this guideline is to assist physicians in the management of patients with cardiovascular pathology and obstructive sleep-disordered breathing. The article consists data on diagnostic tactics for patients with possible sleep-breathing disorders, describes the basic principles of obstructive sleep apnea treatment, and substantiates the clinical significance of obstructive sleep apnea therapy initiating in the management of patients with cardiovascular diseases.

Diverse approaches to the treatment of depressive disorders are necessary to improve evidence-based practice and maximize treatment outcomes. As a result, a range of behaviors and other factors associated with the onset and course of depressive disorders should be examined more comprehensively. Behavioral activation (BA) is a treatment approach to these disorders that can be tailored to address certain health behaviors within the context of depression in an attempt to promote health behaviors whose adoption and maintenance can prove complementary in the treatment of depression. We conducted a scoping review of published studies in which BA-based interventions were used to promote certain health behaviors in individuals with depression. Our search of Medline and the Web of Science identified 336 potential candidate studies. Following screening and with the application of inclusion and exclusion criteria to isolate potentially eligible full-text records, we ultimately identified and evaluated 20 papers that report the nature and efficacy of these modified interventions. Across various domains, including substance use, exercise, medication adherence, and occupational and social success, we found evidence that many--but not all--of the studies we reviewed demonstrated that BA-based interventions were efficacious in promoting the health behavior of interest as well as reducing depressive symptomatology in participants. Implications for more widespread dissemination of such interventions, especially via mobile and web-based platforms due to their accessibility and affordability, are discussed. More research on the feasibility and efficacy of BA-based interventions tailored toward various determinants of health behavior and comorbidities of depressive disorders is warranted.

BACKGROUND: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma. METHODS: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement. RESULTS: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma. CONCLUSIONS: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma.

The zooplankton of the lakes Borodaevskoe and Ferapontovskoe (Russky Sever (Russian North) National Park) has been studied in 1975, 2008, and 2021. The zooplankton composition is similar in the lakes. In total, 70 zooplankton species are registered (21 species of Rotifera, Cladocera, 32, Copepoda, 17). The relict species Limnocalanus macrurus has been found earlier in the lakes. The zooplankton abundance is higher in the shallower Lake Borodaevskoye. The ratio of zooplankton groups in the water bodies was similar throughout the study period, with crustaceans as dominating group. The core of dominants includes 5 to 7 species (Kellicottia longispina, Diaphanosoma brachyurum, Daphnia сucullata, D. сristata, Bosmina coregoni, Mesocyclops leuckarti, and Thermocyclops oithonoides). The zooplankton abundance depends on the water temperature. As the latter has increased by 5 °С in summer 2021, there was an increase in the abundance and biomass of zooplankton in deep water areas of the studied lakes.

GIZh-298 pharmacokinetics was studied in rats after different dosage regimens.The aim of this study was to study GIZh-298 pharmacokinetics after its multiple intragastric administration.Methods. The study was conducted on outbred male rats. The concentrations of GIZh-298 in the blood plasma were determined by HPLC with mass-spectrometric detection. Pharmacokinetic parameters were evaluated using a model-independent method.Results. After single and multiple (4 times with a dosage interval of 3 hours) intragastric administrations at 60 mg/kg dose, the test substance in the blood plasma was determined for 4 hours. The mode of administration of GIZh-298 did not affect the value of its half-life and the mean residence time. It has been established that GIZh-298 accumulates in the rats.

Abstract Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient’s values and target the best outcome possible given the patient’s desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

OBJECTIVE: To evaluate the effects of scleral lens size and the duration of wear on intraocular pressure (IOP) during lens wear. METHODS: Healthy adults were recruited for this prospective and randomized study. Intraocular pressure measurements were performed using a pneumotonometer. A block randomization was used to assign the order of scleral lens diameter of either 15.6 mm or 18.0 mm for 5-hr bilateral wear over a course of two visits. Scleral IOP (sIOP) was measured during the predetermined intervals, 1.25 hr apart, during the 5-hr scleral lens wear. Corneal IOP (cIOP) was measured before and after the scleral lens wear. The primary outcome measure was the mean change in sIOP from prelens insertion baseline. RESULTS: Corneal IOP unchanged after scleral lens removal compared with the baseline measurements ( P =0.878). Smaller and larger lenses introduced significantly higher sIOP at 2.5 hr after lens insertion with the mean (95% CI) increase of 1.16 (0.54, 1.78) mm Hg and 1.37 (0.76, 1.99) mm Hg, respectively. There was no difference in IOP change between the smaller and larger diameter lenses ( P =0.590). CONCLUSIONS: Well-fitted scleral lenses do not result in clinically significant changes in intraocular pressure during 5-hr lens wear in young and healthy individuals.

Laparotomy incisions provide easy and rapid access to the peritoneal cavity in case of emergency surgery. Incisional hernia (IH) is a late manifestation of the failure of abdominal wall closure and represents frequent complication of any abdominal incision: IHs can cause pain and discomfort to the patients but also clinical serious sequelae like bowel obstruction, incarceration, strangulation, and necessity of reoperation. Previous guidelines and indications in the literature consider elective settings and evidence about laparotomy closure in emergency settings is lacking. This paper aims to present the World Society of Emergency Surgery (WSES) project called ECLAPTE (Effective Closure of LAParoTomy in Emergency): the final manuscript includes guidelines on the closure of emergency laparotomy.

Introdução: A púrpura trombocitopênica trombótica (PTT) é considerada uma microangiopatia trombótica grave, de difícil diagnóstico e de tratamento com resposta variável, de patogênese não bem definida quando em associação à infecção pelo HIV e com menor ocorrência após a introdução dos antirretrovirais. Objetivo: Revisar a associação entre PTT e HIV, além de discutir manejo terapêutico da PTT. Método: Relatado caso acompanhado na enfermaria de Infectologia e revisada literatura através de plataformas de pesquisa científica. Resultados: Uma mulher de 32 anos procurou atendimento por cefaleia, febre e vômitos de evolução há 3 dias. No histórico médico pregresso, a paciente apresentava diagnóstico de HIV/AIDS há 12 anos, no momento em uso irregular de TARV. Havia tratado Linfoma de Hodgkin há 7 anos. Ao exame físico estava hipertensa, com taquicardia sinusal, febril e normoglicêmica. O exame físico neurológico, grosseiramente, não apresentava alterações de força ou sensibilidade, porém a paciente não verbalizava e não atendia aos comandos.A paciente foi submetida nesse momento a tomografia de crânio, a qual não evidenciou infarto, hemorragia ou lesão expansiva. A análise do LCR não era sugestiva de processo infeccioso em atividade. Testes laboratoriais adicionais foram realizados. A análise do sangue periférico evidenciou esquizócitos (2+), reticulocitose e plaquetopenia. Achados neurológicos, trombocitopenia e anemia sugerem microangiopatia trombótica, como ocorre na púrpura trombocitopênica trombótica. Como o PLASMIC score foi de 7 pontos, foi coletado material para dosagem ADAMTS13, o qual ainda não obtivemos resultado. Foi iniciada terapia com corticoterapia, rituximabe e plasmaférese e a paciente apresentou melhora progressiva de parâmetros de hemólise, anemia e plaquetopenia, recebendo alta com resolução do quadro clínico. Conclusão: A PTT ocorre por redução menor que 10% da atividade da protease ADAMTS13, favorecendo o acúmulo dos multímeros do fator de Von Willebrand na superfície endotelial com consequente trombocitopenia. A relação entre HIV/AIDS e PTT tem sido relatado em estudos observacionais. A infecção pelo HIV gera impacto direto nas células endoteliais, levando a disfunção e lesão microvascular. Por esse motivo, faz-se necessário o diagnóstico e tratamento precoce visando redução da mortalidade.

Introdução: A esporotricose é uma micose subcutânea causada pelo fungo Sporothrix schenckii, mais comum em pacientes imunocompetentes. No entanto, em pacientes imunocomprometidos, a infecção pode se manifestar de forma mais grave e com maior risco de disseminação. Objetivo: Relatar caso de apresentação rara e atípica da esporotricose. Método: Relatado caso acompanhado na enfermaria de Infectologia e realizada revisão de literatura através de plataformas de pesquisa científica. Resultados: Trata-se de um paciente masculino de 38 anos com diagnóstico recente de HIV/Aids e em uso regular de terapia antirretroviral. Apresentava CD4 de 85 células/mm3 no momento do diagnóstico e 180 células/mm3 no momento da internação. Ele desenvolveu uma lesão ulcerada e verrucosa em orofaringe, próxima à úvula, com evolução de 10 meses, associada a dor intensa e sangramentos eventuais. Além disso, relatava cansaço aos esforços, febre eventual, sudorese noturna e perda ponderal significativa. Testes point-of-care para tuberculose, criptococose e histoplasmose tiveram resultados negativos. A biópsia da lesão resultou na identificação de Sporothrix schenckii em cultura. O tratamento ambulatorial com itraconazol não obteve resposta clínica satisfatória, necessitando de nova internação para tratamento com anfotericina B. Durante o tratamento com anfotericina B, o paciente apresentou melhora progressiva dos sintomas, com redução da dor, cicatrização da lesão orofaríngea e recuperação do estado nutricional. Após 10 dias de tratamento, o paciente recebeu alta hospitalar com orientações para continuidade do itraconazol por via oral. Conclusão: A esporotricose em pacientes imunocomprometidos pode se manifestar de forma mais agressiva e de difícil tratamento. A terapia antifúngica é a principal forma de tratamento, sendo o itraconazol a opção de primeira linha em casos menos graves. No entanto, em casos mais graves ou com falha terapêutica, a anfotericina B pode ser necessária. No caso descrito, o paciente apresentou uma forma potencialmente grave de esporotricose orofaríngea, com falha terapêutica ao itraconazol e necessidade de tratamento com anfotericina B. Pacientes com HIV/Aids apresentam maior risco de infecções fúngicas oportunistas, como a esporotricose, que podem se manifestar de forma mais grave. O diagnóstico precoce e o tratamento adequado são fundamentais para o manejo desses casos. No caso apresentado, a utilização da anfotericina B foi crucial para a resolução do quadro clínico do paciente.

Introdução: A nefrite intersticial aguda é uma complicação rara, porém grave, da tuberculose disseminada em pacientes imunocomprometidos. Objetivo: Revisar métodos diagnósticos, manifestações clínicas e terapêutica da nefrite intersticial aguda secundária à tuberculose disseminada. Método: Relatado caso acompanhado na enfermaria de Infectologia e revisada literatura através de plataformas de pesquisa científica. Resultados: Paciente masculino, de 35 anos, previamente hígido. Estava apresentando há um ano perda ponderal significativa (30 kg) e fadiga. Evolui com febre vespertina diária, sudorese noturna e adenomegalia cervical. Realizou testes rápidos com diagnóstico de infecção pelo HIV, sendo iniciada imediatamente terapia antirretroviral com TDF/3TC + DTG. Cerca de 5 dias após início do tratamento evoluiu com alteração de comportamento, vômitos, inapetência e oligúria. Foi então admitido na emergência com quadro de injúria renal aguda e necessidade de terapia renal substitutiva. Em investigação adicional, os exames laboratoriais evidenciaram uma CV-HIV de 15.700 cópias, CD4 58 (2.95%), presença de adenomegalias difusas em região cervical, retroperitônio e mediastino, além de micronódulos pulmonares randômicos. Submetido à fibrobroncoscopia e biópsia de gânglio cervical, sendo nesse momento diagnosticado com tuberculose disseminada com confirmação histológica e microbiológica em gânglio cervical e lavado broncoalveolar. Iniciado RHZE, porém sem evidência de recuperação de função renal após 45 dias de tratamento. Realizado biópsia renal com infiltrado inflamatório intersticial linfocitário com tubulite e infiltração de eosinófilos, conclusão de nefrite tubulointersticial aguda (Imagem 1). Impressão de dano tubular direto causado pelo Mycobacterium tuberculosis. Optado por iniciar terapia com corticosteroide, prednisona 1mg/kg por 15 dias e redução gradual de de dose após. Paciente evoluiu com recuperação completa de função renal, sem necessidade de hemodiálise, além de melhora clínica. CONCLUSÃO: A nefrite intersticial por tuberculose é uma manifestação rara da doença em pacientes imunossuprimidos, geralmente acompanhada de tuberculose extra-renal. É caracterizada por granulomas intersticiais, cuja fisiopatologia ainda não é completamente elucidada. A nefrite intersticial secundária à tuberculose não responde à terapia com antituberculostáticos isoladamente, sendo recomendada a associação de corticosteroides.

Introdução: A Doença de Whipple (DW) é uma infecção sistêmica crônica insidiosa rara causada pelo bacilo gram-positivo Tropheryma whipplei. Acomete principalmente homens brancos de meia idade, tem relação com áreas rurais e os principais sintomas são artralgia, perda de peso, dor abdominal e diarreia. Objetivo: Discutir a possibilidade de erro diagnóstico pela histopatologia em doenças infecciosas. MÉTODO: Relatado caso acompanhado na enfermaria de Infectologia e revisada literatura através de plataformas de pesquisa científica. Resultados: Trata-se de um homem de 60 anos, agricultor, imunocompetente, com história de gota tofácea. Teve duas internações nos últimos anos por histoplasmose disseminada com diagnóstico por biópsia de estômago e duodeno. Foi apenas realizada coloração por prata e Ziehl Neelsen (ZN), sem envio do material para cultura. Foi tratado adequadamente com indução com Anfotericina B e manutenção com Itraconazol. Chegou a usar antibióticos de amplo espectro nas internações devido a infecções nosocomiais. Retorna 3 meses após término do tratamento com itraconazol com quadro de diarreia, vômitos, dor abdominal, astenia e poliartralgias, sintomas semelhantes às internações prévias. Apresentou perda ponderal de 10kg neste período e estava inapetente, mas negava febre. Foi optado por não iniciar Anfotericina e solicitar nova endoscopia digestiva alta (EDA) e pesquisa de imunodeficiência primária, visto quadro prévios de possível histoplasmose disseminada. Na EDA foram visualizadas áreas com pontilhado enantematoso na primeira e segunda porções duodenais, realizadas biópsias para envio para cultura e anatomopatológico (AP). Também foram realizadas tomografias computadorizadas de abdome, mostrando esplenomegalia, e de tórax, sem lesões visualizadas. No AP foi rapidamente identificado após realização das colorações de prata (1), ZN e ácido periódico de Schiff (PAS) (2) o agente etiológico, Tropheryma whipplei. Foi iniciado tratamento com ceftriaxona por 2 semanas com melhora clínica dentro dos primeiros 2 dias de antibioticoterapia e após recebeu alta com terapia de manutenção com sulfametoxazol+trimetoprima. A investigação de imunodeficiência primária veio negativa e os cultivos vieram negativos para fungos. Conclusão: O diagnóstico da DW se dá pela suspeição clínica e métodos histopatológicos de detecção corretos, visto morfologia semelhante a outros agentes infecciosos. A correta coloração no AP é essencial para o diagnóstico, principalmente a realização do PAS.

Introdução: A cromoblastomicose (CBM), infecção fúngica crônica limitada à pele e subcutâneo, é rara no estado do Rio Grande do Sul, com incidência de cerca de 2,6 casos no ano. Objetivo: Revisar métodos diagnósticos e terapêutica de Cromoblastomicose e relatar o caso devido à baixa prevalência no Rio Grande do Sul. Método: Relatado caso acompanhado na enfermaria de Infectologia e revisada literatura através de plataformas de pesquisa científica. Resultados: Paciente de 46 anos, previamente hígido, é encaminhado para internação para investigação de lesão verrucosa. Tinha histórico de trauma no joelho esquerdo em 2004. Desde então, apresentava lesão extensa na região patelar, alternando entre períodos de melhora e piora. Há dois anos, iniciou com lesões verrucosas em joelho esquerdo com distribuição centrífuga a partir da lesão inicial, associadas a prurido e sangramento eventual, sem outros sintomas. Atendido na sua cidade de origem, onde iniciou tratamento com Itraconazol e terbinafina. Ao exame físico, o joelho esquerdo apresentava lesões verrucosas, hiperemiadas, algumas com crostas hemáticas, de tamanho variando. Biópsia do local com presença de células muriformes, sendo compatível com CBM. A partir disso, foi instituída terapia com dose ajustada de itraconazol associado a flucitosina. Paciente mantido internado para avaliação de possíveis efeitos adversos destas medicações; uma vez que não demonstrou sinais, sintomas e alterações laboratoriais que sugerissem estes efeitos, teve alta para continuidade de tratamento e acompanhamento de forma ambulatorial. Na alta, já apresentava melhora das lesões. Conclusão: A CBM é uma micose de inoculação traumática, mais prevalente em regiões tropicas e subtropicais, causada por fungos negros encontrados no solo, espinhos e vegetação em decomposição. O agente etiológico mais frequente é o Fonsecaea pedrosoi que é de difícil erradicação, necessitando de longos períodos de tratamento e com altas taxas de recidiva.

Introdução: A epididimite/orquiepididimite tuberculosa é um desafio diagnóstico. No entanto, algumas pistas clínicas podem ajudar, incluindo a busca pela TB extragenial, resposta pobre aos antimicrobianos e lesões cutâneas escrotais. Objetivo: Relatar caso de tuberculose genital, discutir o diagnóstico e terapêutica. Método: Relatado caso acompanhado na enfermaria de Infectologia e realizada revisão de literatura em plataformas de pesquisa científica. Resultados: Paciente de 21 anos, previamente hígido, com tratamento prévio para epididimite há 3 meses, sem resolução do quadro, procura atendimento por afasia e parestesia em hemicorpo direito de início súbito. Perda ponderal e febre associados, sem outros sinais e sintomas. Ao exame físico, aumento importante de bolsa escrotal à direita, com hiperemia e ponto de supuração. TC crânio evidenciando múltiplas lesões nodulares no parênquima encefálico, especialmente no cerebelo. Ecodoppler de bolsa escrotal sugeriu áreas nodulares hipoecoicas com áreas internas liquefeitas sugestivas de doença granulomatosa. RNM bolsa escrotal reforçou características de tuberculose geniturinária e descartou malignidade. Paciente realizou TC tórax com padrão sugestivo de doença miliar, submetido a fibrobroncoscopia com detecção de Genexpert MTB e cultura positiva para Mycobacterium tuberculosis, multissensível em lavado broncoalveolar. LCR do paciente com pleocitose com predomínio de linfócitos, proteinorraquia e consumo de glicose, sugerindo meningoencefalite tuberculosa, posterior confirmação com identificação de PCR para Mycobacterium tuberculosis. Iniciado tratamento com rifampicina, isoniazida, pirazinamida e etambutol associado à dexametasona por TB disseminada com comprometimento de SNC. Após início da terapia, paciente apresentou importante melhora do quadro clínico, com resolução total dos sintomas neurológicos. Após investigação, não se encontrou imunodeficiência primária ou adquirida. Conclusão: Entre o amplo espectro de manifestações clínicas atípicas da TB, este relato de caso chama a atenção para o desafio diagnóstico, especialmente em pacientes imunocompetentes.

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

BACKGROUND: Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The timing in acute care surgery (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts. METHODS: This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease. RESULTS: Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority. CONCLUSION: The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a safe timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

The pharmacokinetics of a new antiparkinsonian drug ADK-1113 after single intravenous and intragastric administrations in mice at doses of 10 and 20 mg/kg was studied. The absolute bioavailability was 10.1–16.3 % that indicates on potential possibility of preparing a dosage form for oral administration.

Research on the military-technogenic burden on the natural environment as a result of international conflicts is relevant since military operations cause catastrophic consequences for the environment and natural resources, which can lead to irreversible disturbances in ecosystems. The study is devoted to the examination of the impact of military-technogenic loads on the soils of military training grounds. The paper considers methods of soil sampling and their analysis for the content of heavy metals and other chemical compounds and determines the impact of this load on the ecosystem and possible consequences for human health. The influence of military activity on the soil quality of military training grounds, in particular in the Cherkasy region, is analysed. The study includes the determination by X-ray fluorescence and atomic emission method of the content of various elements in the soil. The results showed a substantial iron content, which may be due to the use of explosives in military exercises. It is noted that despite the fact that exceeding the norms of maximum permissible content concentration, no heavy metals were recorded in the examined soils, and the maximum lead content approached the maximum permissible concentration, which requires further monitoring and control of this parameter. Ph determination showed a slightly acidic soil condition in combat exercise sites, which can affect plant fertility and growth. The content of nitrogen, phosphorus, potassium, and boron was assessed, and the results showed a lack of these nutrients for normal plant development. It is established that soil damage as a result of military operations can have a long-term negative impact and pose a threat to residents and territories. The results of the tests indicate a slight technogenic load at the sites of military exercises. The detected contamination of the examined samples is insubstantial, which indicates that the impact of military activities on the soil condition is limited. The results of the study will help to understand the possible health risks for people living near military training grounds and respond appropriately to protect their health

Abstract Background The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. Methods Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. Results The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient’s directives, family feelings and representatives' desires, and all decisions should be shared. Conclusions The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes. Graphical abstract

Abstract Background Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann’s procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P