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Background Acute Care Surgery (ACS) is a rapid response system in emergency surgical conditions. The patients who over 60 year-old have numerous factors associated with high mortality and morbidity in emergency colorectal surgery. We aimed to identify potentially preventable risk factors, to improve patients’ outcomes. Methods A retrospective review of patients age over 60 year-old undergoing emergency colorectal surgery in the ACS service from August 1, 2017 through November 30, 2019. Results Ninety-two patients were analyzed, average age 72.41 years. The most common diagnosis was complicated colorectal cancer (76, 83.52%) with locations on the right (37, 41.51%), left (35,39.33%), and rectum (17, 19.10%). Clinical presentations were obstruction without perforation (61, 67.03%), perforation (25, 27.17%), and ischemia (2, 2.17%). Overall mortality was 6.52%. Cause of death included septic shock (3, 50%); respiratory failure (3, 50%); and pulmonary embolism (1, 16.67%). Morbidity from surgical and medical complications were 41.30% and 26.08%, respectively. For all causes, operations included resection with primary anastomosis (62, 71.26%); Hartmann's operation (11, 12.64%); and loop colostomy (12, 13.79%). Average operative time was 159.86 min. In emergency colorectal surgery, pre-existing heart disease, clinical perforation, and ventilator dependency increased risk of death 7.6-, 16.5-, and 0.08-fold, respectively. Conclusion Clinical perforation leads to sepsis and septic shock in older patients, this may be modifiable to improve mortality by developing an early, rapid, protocol-driven surgical sepsis fast-track process. Ventilator dependency is potentially modifiable with postoperative advanced surgical critical care. The non-modifiable risk factor of co-morbid heart disease might be improved by postoperative advanced critical care for close monitoring., Highlights • Most of emergency colorectal surgeries resulted from complications of colorectal cancer; age was not a contraindication for resection with primary anastomosis. • Clinical perforation leads to sepsis and septic shock in older patients. This may be modifiable to improve mortality by developing an early, rapid, protocol-driven surgical sepsis fast-track process. • Ventilator dependency is potentially modifiable with postoperative advanced surgical critical care. • Preoperative nutrition status, other comorbidities, preoperative anticoagulant use, location of disease, operative time, intraoperative fluid replacement, and blood loss were not risk factors of increased mortality.

Background Coronavirus disease (COVID-19) has impacted both emergency and elective surgical management owing to its highly infectious nature and the shortage of personal protective equipment. This study aimed to review the outcomes of emergency surgical conditions and trauma during the pandemic lockdown. Material and methods We retrospectively reviewed and collected data from patients who attended the Acute Care Surgery Service from 1st April to May 31st, 2020 during Thailand's COVID-19 pandemic lockdown. We separated staff and performed preoperative COVID-19 swab testing on all patients to assess the requirement for personal protective equipment. Compared with previous years of service, of 2018 and 2019. Preoperative COVID-19 testing was performed using multiplex and manual RT-PCR. Morbidity and mortality, consultation time, and waiting time to surgery were analyzed. Results A total of 61 patients were enrolled. The average age of patients was 53.8 years. The average consultation time, waiting time to surgery, and surgical duration were 10 min, 660 min, and 88.77 min, respectively. The average time taken to obtain the preoperative COVID-19 test result was 227.26 min. The morbidity and mortality rates were 9.84% and 1.64%, respectively. Compared with the same period in 2018 and 2019, consultation time was significantly faster (10 min; p = 0.033) and waiting time to surgery was significantly longer (660 min, respectively; p = 0.011). Morbidity and mortality between pandemic period and the previous year of service were not significantly different. No medical workers were infected with COVID-19. Conclusions During the COVID-19 pandemic, optimal triage of emergency patients is key. Waiting for preoperative COVID-19 swab testing in emergency case is safe and results in good outcomes. Although the waiting time to surgery was significantly longer owing to the time required to receive preoperative COVID-19 swab results, morbidity and mortality rates were unaffected., Highlights • Effective and optimal triage is a key to guide management. • Preoperative COVID-19 swab testing to adjust resources for good outcomes. • Waiting for preoperative COVID-19 swab test before performing surgery is safe for patients and medical workers.

Background: Acute Care Surgery (ACS) is a rapid response system in emergency surgical conditions. Older patients have numerous factors associated with high mortality and morbidity in emergency colorectal surgery. We aimed to identify potentially preventable risk factors, to improve older patients’ outcomes.Methods: A retrospective review of patients over 60 years old undergoing emergency colorectal surgery in the ACS service from 1 August 2017 through 30 November 2019.Results: Data of 92 patients were analyzed, average age 72.41 years. The most common diagnosis was colorectal cancer (76, 83.52%) with locations on the left (37, 41.51%), right (35,39.33%), and rectum (17, 19.10%). Clinical presentations were obstruction without perforation (61, 67.03%), perforation (25, 27.17%), and ischemia (2, 2.17%). Overall mortality was 6.52%. Cause of death included septic shock (3, 50%); respiratory failure (3, 50%); and pulmonary embolism (1, 16.67%). Morbidity from surgical and medical complications were 41.30% and 26.08%, respectively. For all causes, operations included resection with primary anastomosis (62, 71.26%); Hartman procedure (11, 12.64%); loop colostomy (12, 13.79%); and percutaneous drainage with antibiotics (2, 2.3%). Average operative time 159.86 minutes. In emergency colorectal surgery, preexisting heart disease, clinical perforation, and ventilator dependency increased risk of death 7.6-, 16.5-, and 0.08-fold, respectively. Conclusion: Preexisting heart disease and clinical perforation were unmodifiable risk factors for mortality among older patients undergoing emergency colorectal surgery; ventilator dependency is potentially modifiable with advanced surgical critical care. Early, rapid, protocol-driven processes might help reduce mortality in patients with clinical presentation of perforation.

Diagnosis plot between missing and observed values: A) WBC, B) Neutrophil. (PDF 157 kb)

Receiver operating characteristic (ROC) curves of RAMA-AS for diagnosis of appendicitis. (PDF 153Â kb)

Re-calibration and revision of models for external validations. Table S2. Report number of missing data. Table S3. Distributions of predictors by appendicitis groups and developed/validated data. Table S4. Estimation of intercept and coefficients for external validations using different update models. Table S5. Estimations of calibration coefficients and C-statistics for external validations using different re-calibration and revision methods. (DOCX 57Â kb)

A 27-year-old Thai male was admitted with left groin pain and he felt that he lost his left testis three weeks after his motorcycle accident-car collision. He had not been diagnosed after four days of admission at the previous hospital. Surgical reduction was performed without acute and delayed complications after three months of follow-up. Traumatic testicular dislocation is an uncommon sequel of trauma usually related to straddle injury from motorcycle accidents. Diagnosis depends on the awareness of the physician of its possibility of occurrence. Physical examination is the most helpful in diagnosis. CT scan or Doppler ultrasound, if available, may be helpful in diagnosis, particularly locating the extrascrotal testicle and detecting testicular viability. Manual reduction is the treatment of choice for acute traumatic dislocation of testis. Open reduction is indicated for the delayed case, or if there are (1) difficulty in determining the integrity of dislocated testis, (2) possibility of torsion, (3) failure of close reduction, or (4) the minimal morbidity of an inguinal exploration.

Angiogenesis is important in the process of tumor growth and progression of breast cancer Microvessel density (MVD) is the most commonly used technique to quantify intratumoral angiogenesis in breast cancer. In the present study, the authors investigated the prognostic indicator of intratumoral MVD in predicting overall survival, disease recurrence, and distance metastasis of breast cancer.Two hundred patients who were diagnosed as invasive breast cancer from January 2000 to December 2004 were included in the present study, but only 64 patients had complete pathological specimens and tumor receptor studies. Representative paraffin sections of the primary tumor including the tumor border were immunostained with a monoclonal anti-CD34 antibody. The area of highest vascular density ("hot spot") was identified and the average count of three hot spots in each tumor was used for analyses. The distribution of MVD was categorized into high and low MVD as more than 76 and less than 76 respectively. Overall survival probability was estimated by the Kaplan-Meier method. A multivariate Cox regression was employed to examine the relationship between MVD and disease outcomes while adjusting for other concomitant variables.The tumor size and more advanced disease have correlated with poor outcomes of invasive breast cancer. Tumor size is a poor predictor for local recurrence [Harzard ratio 1.02 (95% CI 0.99-1.04)] and more disease staging have correlated with distance metastases [Harzard ratio 1.48 (95% CI 0.98-2.24)]. The cancer staging only predicted poor outcome in invasive breast cancer in overall recurrence [Harzard ratio 1.51 (95% CI 1.05-2.16)]. MVD is not correlated with both tumor recurrence and distance metastases [Hazard ratio for local recurrence 1.01 (95% CI 0.99-1.04) and Harzard ratio 1.00 (95% CI 0.97-1.02)].The microvessel density (MVD) has not predicted poor outcomes of invasive breast cancer in Thai woman.