Immediate versus expedient emergent laparotomy in unstable isolated abdominal trauma patients.

INTRODUCTION: Unstable abdominal trauma patients should be treated with emergent laparotomy. However, few studies have evaluated the association between time to surgery and survival in these patients. We aimed to assess the influence of time to laparotomy on outcomes in blunt and penetrating unstable abdominal trauma patients. METHODS: This retrospective study includes patients with abdominal injuries, systolic blood pressure <90mmHg on arrival, admitted in Israel during 2000-2018. Data regarding patients' characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), time to surgery, length of hospital stay and mortality were collected via The Israeli National Trauma Registry. RESULTS: Overall, 69 blunt and 127 penetrating injury patients were included in the study. For blunt and penetrating trauma patients with ISS ≤14, no differences in outcome were found between patients who underwent laparotomy within 60min of admission and those who underwent laparotomy within 60-120min of admission. In patients with blunt trauma, ISS ≥16, and GCS <15, mortality was higher in the immediate laparotomy group (p = 0.004 and 0.049, respectively). CONCLUSIONS: In patients with a penetrating injury, no differences in mortality between immediate and expedient laparotomy were demonstrated. In patients with a blunt injury, with ISS ≥16 and GCS <15, mortality was higher among the immediate laparotomy group.

Ethical Considerations and Outcomes in Body Contouring Surgeries Among Adolescents: A Comprehensive Narrative Review.

BACKGROUND: Body contouring surgery (BCS) in adolescents, particularly following bariatric surgery, involves a complex array of ethical, psychological, and medical factors. This review focuses on adolescents who have experienced significant weight loss, often due to bariatric surgery, and subsequently require body contouring to address excess skin and soft tissue. METHODS: A literature narrative review was conducted using PubMed and Google Scholar databases. Relevant articles were screened and selected based on their discussion of post-bariatric and massive weight loss body contouring surgeries in adolescents, focusing on prevalence, outcomes, and ethical considerations. RESULTS: The prevalence of BCS among adolescents is rising, influenced by social media and societal perceptions of beauty. However, the percentage of adolescents receiving BCS after bariatric surgery remains low. Adolescents undergoing BCS experience improvements in physical functioning, body image, and psychological well-being. Complications, although common, are mostly minor. Ethical considerations include ensuring informed consent, assessing emotional maturity, managing patient expectations, and involving adolescents in decision-making. Comparative analysis reveals similar outcomes in adults and adolescents, but adolescents face unique ethical challenges related to autonomy, long-term effects, and ongoing physical and emotional development. CONCLUSION: BCS in adolescents following bariatric surgery can lead to improved physical and psychological outcomes. However, the decision to undergo BCS must be carefully considered, taking into account the adolescent's maturity, expectations, and long-term well-being. Ethical considerations are paramount, emphasizing the need for informed consent, realistic expectations, and a multidisciplinary approach. Further research is needed to assess long-term outcomes and the specific ethical implications of BCS in adolescents compared to adults. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Early vs delayed insertion of penile prosthesis in patients with refractory priapism: a systematic review and meta-analysis.

INTRODUCTION: Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking. OBJECTIVES: To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED). METHODS: We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model. RESULTS: We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group. CONCLUSION: The results from this study favor an early approach to ED (within 30 days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.

[Research progress of rapid surgery for hip fracture in elderly patients].

Objective: To review the research progress of rapid surgery for hip fracture in elderly patients. Methods: The published studies, expert consensus, and guidelines at home and abroad were systematically summarized from the aspects of the characteristics of aging population, the benefits of rapid surgery, the disadvantages of delayed surgery, and the recommendations of current guidelines, so as to further guide clinical practice. Results: Hip fracture is a common fracture type in the elderly population. As elderly patients generally have poor physique and often have a variety of underlying diseases, such as hypostatic pneumonia, bedsore, lower limb vein thrombosis, and other complications in conservative treatment, its disability rate and mortality are high, so surgical treatment is the first choice. At present, most relevant studies and expert consensus and guidelines at home and abroad support rapid surgery, that is, preoperative examination should be started immediately after admission, and adverse factors such as taking anticoagulant drugs, serious cardiovascular diseases, and severe anemia should be clearly and actively corrected, and surgery should be completed within 48 hours after admission as far as possible. Rapid surgery can not only significantly reduce the mortality of patients, but also reduce the length of hospital stay and the incidence of perioperative cognitive impairment, which is conducive to the recovery of patients with pain during hospitalization and postoperative function, and improve the prognosis of patients. Conclusion: In order to avoid many problems caused by delayed surgery, the elderly patients with hip fracture should be operated as soon as possible under the condition of actively correcting the adverse factors. Comprehensive evaluation and preparation, the development of an individualized surgical plan, and the formation of a multidisciplinary medical team can reduce surgical risks and improve effectiveness.

The impact of time from injury to surgery on the risk of neuropathic pain after traumatic spinal cord injury.

Traumatic spinal cord injury (SCI) is a devastating neurological disorder often accompanied by neuropathic pain (NeP), significantly affecting patients' quality of life. This retrospective study aimed to investigate the impact of the time from injury to surgery on the development of NeP following traumatic SCI. Medical records of patients with traumatic SCI who underwent surgical intervention between January 2017 and January 2021 at two specialized centers were reviewed. Variables associated with NeP including demographics, injury profiles, medical history, surgical details, and pain assessments were investigated. Independent risk factors related to NeP were identified using multivariate logistic regression analysis. A total of 320 patients met the inclusion criteria, with 245 (76.6%) being male and a mean age of 56.5 ± 13.2 years. NeP was identified in 48.4% of patients (155 of 320). The multivariate analysis identifies age at injury, Injury Severity Score, and the neurological level of injury as independent risk factors for the development of NeP in both AIS A and AIS B, C, and D subgroups. Additionally, a significant association between the time from injury to surgery and NeP was observed in AIS B, C, and D patients, while no such association was found in AIS A patients. This study highlights the benefits of early and ultra-early surgical intervention in preventing NeP in patients with incomplete traumatic SCI (AIS B, C, and D), underscoring the importance of optimizing surgical timing to improve patient outcomes. Prospective studies are warranted to establish evidence-based surgical guidelines for managing traumatic SCI and preventing NeP effectively.

Influence of age and severity of Lenke 5 or 6 idiopathic scoliosis on postoperative quality of life in adult patients.

INTRODUCTION: Thoracolumbar adolescent idiopathic scoliosis can continue to progress beyond skeletal maturity. Ideal timing of surgery remains undefined. Earlier intervention, with shorter instrumentation, incurs early partial loss of lumbar motion. Waiting for progression incurs a greater risk of extensive arthrodesis. The aim of the present study was to assess the quality-of-life impact of age and scoliosis severity at surgery. MATERIAL AND METHODS: Patients with Lenke 5 or 6 adolescent idiopathic scoliosis, aged 16-45years, were analyzed based on a prospective clinical registry. Oswestry Disability Index (ODI) and Scoliosis Research Society (SRS)-22 scores were collected preoperatively and at 6months, 1year and 2years. Coronal and sagittal alignments were measured on full-spine radiographs, and curve flexibility was assessed on bending radiographs. A mixed linear model was used to assess the impact of age, Cobb angle and flexibility on quality of life. RESULTS: Thirty-six patients were included. Mean ODI was 20.5% preoperatively and 13.8% at 2years (p=0.017). Mean SRS-22 was 3.2 preoperatively and 3.9 at 2years (p<0.001). Mean Cobb angle was 56.6° preoperatively and 23.2° at 2years (p<0.001), with mean preoperative reducibility of 68.1%. Age and ODI correlated preoperatively (r=0.6; p<0.001) and at 6months (r=0.5; p=0.002), as did age and SRS-22 (r=-0.6; p<0.001 and r=-0.6; p<0.001, respectively). Linear regression found a significant negative correlation between thoracolumbar Cobb angle and change in SRS-22 at 6months. DISCUSSION: In 16-45 year-olds with Lenke 5 or 6 idiopathic scoliosis, age influenced SRS-22 score. Younger patients had better quality of life both pre- and post-operatively. Curve magnitude influenced postoperative score. The present study suggests that early surgical correction in younger patients, where instrumentation can be shorter, does not impair quality of life. LEVEL OF EVIDENCE: IV; prospective registry study.

Delaying ACL reconstruction is associated with increased rates of medial meniscal tear.

PURPOSE: The aim of this study was to evaluate the relationship between the time from injury to ACL reconstruction (ACLR) and the rate as well as repairability of meniscal tears. Secondary aims were to evaluate the relationship between meniscal injury and Tegner Activity Scale, age, BMI, and gender. METHODS: Between 2012 and 2022, 1,840 consecutive ACLRs were performed. A total of 1,317 ACLRs were included with a mean patient age of 31.2 years ± 10.5 [16-60]. Meniscal tear was assessed during arthroscopy using the ISAKOS classification. Time from injury to ACLR, Tegner Activity Scale, age, BMI and gender were analysed in uni- and then in multivariate analyses. Patients were divided into four groups according to the time from injury to surgery: < 3 months (427; 32%), 3-6 months (388; 29%), 6-12 months (248; 19%) and > 12 months (254; 19%). RESULTS: Delaying ACLR > 12 months significantly increased the rate of medial meniscal (MM) injury (OR 1.14; p < 0.001). No correlation was found between a 3- or 6-month time from injury to surgery and MM tear. Performing ACLR > 3, 6, or 12 months after injury did not significantly increase the rate of lateral meniscal (LM) injury. Increasing Tegner activity scale was significantly associated with a lower rate of MM injury (OR 0.90; p = 0.020). An age > 30 years (OR 1.07; p = 0.025) and male gender (OR 1.13; p < 0.0001) was also associated with an increased rate of MM injury. Age > 30 years decreased the rate of MM repair (OR 0.85; p < 0.001). Male gender increased the rate of LM tear (OR 1.10; p = 0.001). CONCLUSION: Performing ACLR more than 12 months after injury was associated with increased rates of MM injury but not with lower rates of repairable lesions. An increased pre-injury Tegner activity score was associated with a decreased rate of MM tear. Age > 30 years was associated with an increased rate of MM tear with concomitant ACL injury and a decreased rate of repairability of MM tear. ACLR should be performed within 12 months from injury to prevent from the risk of MM injury. LEVEL OF EVIDENCE: Level III.

Allocating operating room capacity to non-elective neurosurgical patients improves access and safety for elective patients at Aarhus University Hospital.

INTRODUCTION: This study addresses surgical scheduling within the Department of Neurosurgery at Aarhus University Hospital (AUH). The department provides neurosurgical care to a population of 1.3 million in central Denmark, and has treatment obligations for specific neurosurgical diseases for the entire country, which has a population of 5.8 million. Efficient utilisation of the department's four operating suites is crucial to ensure that patients have timely access to both non-elective and elective neurosurgical procedures. Historically, the elective operating room (OR) schedule was made without consideration of the possible arrival of non-elective patients; consequently, elective surgeries were often cancelled to accommodate those with more urgent indications. The challenge was thus to introduce a structured way of planning for these non-elective surgical procedures that would minimise the need for cancelling elective surgeries without decreasing overall productivity. METHODS: Using a mathematical model developed in a previous study at Leiden University Medical Center, the effect of allocating OR time during regular working hours for non-elective neurosurgical procedures at AUH was analysed, so that a weighted trade-off could be made between cancellations of elective patients due to an overflow of non-elective patients and unused OR time due to excessive reservation of time for non-elective patients. This allocation was tested in a six-week pilot study during weeks 24 & 25 and weeks 34-37 of 2020 before being implemented in 2021. RESULTS: In the 35 weeks following the implementation, the new allocation strategy resulted in a significant 77% decrease in the cancellation of elective neurosurgical procedures when compared with the same time period in 2019, with a significant 16% increase in surgical productivity. CONCLUSIONS: This study shows that with mathematical modelling complex problems in the distribution of neurosurgical OR capacity can be solved, improving both patient safety and the working environment of neurosurgeons and OR staff.

Optimizing The Timing of Stereotactic Minimally Invasive Drainage for Hypertensive Intracerebral Hemorrhage.

INTRODUCTION: Intracerebral hemorrhage is a high-risk pathological event that is associated with formidable morality rates. Here, our objective was to perform a retrospective study to determine the best timing for drainage using physiological data on patients who received drainage at different timings. METHODS: In this retrospective study, we reviewed 198 patients with hypertensive cerebral hemorrhage who underwent stereotactic drainage at the conventional timing (surgery within 12 h of admission; control group) and 216 patients who underwent stereotactic drainage at a customized surgical timing (elective group). Follow-ups were performed at 3 and 6 months after surgery. RESULTS: The clinical indicators, including prognosis, hematoma clearance, recurrent hemorrhage, intracerebral infection, pulmonary infection, deep venous thrombosis, gastrointestinal hemorrhage, National Institutes of Health Stroke Scale scores, and matrix metallopeptidase 2 and 9 levels, were compared between the control and elective groups. Our data indicated that the elective group had significantly better prognosis compared to the control group (p = 0.021), with a higher rate of hematoma clearance (p = 0.004) and a lower rate of recurrent hemorrhage (p = 0.018). The total occurrence rate of post-surgery complications was also lower for the elective group (p = 0.026). NIHSS scores and serum MMP2/9 levels of the elective group were lower than those of the control group. CONCLUSIONS: Customized timing of stereotactic drainage may be superior to conventional fixed timing (within 12 h post-hemorrhage) in reducing post-surgery complications and promoting recovery, which supports the potential use of customized timing of stereotactic minimally invasive drainage as a new convention in clinics.

Research progress of rapid surgery for hip fracture in elderly patients / 中国修复重建外科杂志

OBJECTIVE@#To review the research progress of rapid surgery for hip fracture in elderly patients.@*METHODS@#The published studies, expert consensus, and guidelines at home and abroad were systematically summarized from the aspects of the characteristics of aging population, the benefits of rapid surgery, the disadvantages of delayed surgery, and the recommendations of current guidelines, so as to further guide clinical practice.@*RESULTS@#Hip fracture is a common fracture type in the elderly population. As elderly patients generally have poor physique and often have a variety of underlying diseases, such as hypostatic pneumonia, bedsore, lower limb vein thrombosis, and other complications in conservative treatment, its disability rate and mortality are high, so surgical treatment is the first choice. At present, most relevant studies and expert consensus and guidelines at home and abroad support rapid surgery, that is, preoperative examination should be started immediately after admission, and adverse factors such as taking anticoagulant drugs, serious cardiovascular diseases, and severe anemia should be clearly and actively corrected, and surgery should be completed within 48 hours after admission as far as possible. Rapid surgery can not only significantly reduce the mortality of patients, but also reduce the length of hospital stay and the incidence of perioperative cognitive impairment, which is conducive to the recovery of patients with pain during hospitalization and postoperative function, and improve the prognosis of patients.@*CONCLUSION@#In order to avoid many problems caused by delayed surgery, the elderly patients with hip fracture should be operated as soon as possible under the condition of actively correcting the adverse factors. Comprehensive evaluation and preparation, the development of an individualized surgical plan, and the formation of a multidisciplinary medical team can reduce surgical risks and improve effectiveness.

Instantaneous death risk, conditional survival and optimal surgery timing in cervical fracture patients with ankylosing spondylitis: A national multicentre retrospective study.

Background: The mortality rate in patients with ankylosing spondylitis (AS) and cervical fracture is relatively high. Objectives: This study aimed to investigate the instantaneous death risk and conditional survival (CS) in patients with AS and cervical fracture. We also studied the relationship between surgical timing and the incidence of complications. Methods: This national multicentre retrospective study included 459 patients with AS and cervical fractures between 2003 and 2019. The hazard function was used to determine the risk of instantaneous death. The five-year CS was calculated to show the dynamic changes in prognosis. Results: The instantaneous death risk was relatively high in the first 6 months and gradually decreased over time in patients with AS and cervical fracture. For patients who did not undergo surgery, the instantaneous risk of death was relatively high in the first 15 months and gradually decreased over time. For patients with American Spinal Injury Association impairment scale (ASIA) A and B, the 5-year CS was 55.3% at baseline, and improved steadily to 88.4% at 2 years. Odds ratios (ORs) for pneumonia, electrolyte disturbance, respiratory insufficiency, and phlebothrombosis decreased as the surgery timing increased. Conclusion: Deaths occurred mainly in the first 6 months after injury and gradually decreased over time. Our study highlights the need for continued surveillance and care in patients with AS with cervical fractures and provides useful survival estimates for both surgeons and patients. We also observed that early surgery can significantly increase functional recovery, and decrease the incidence of complications and rehospitalisation.

Protective and Risk Factors for Humerus Head Necrosis After Proximal Humerus Fracture Treated with Internal Locking Plate.

BACKGROUND: Proximal humerus fractures (PHF) are common and lead to post-traumatic humerus head necrosis (HHN) in 3-35% after ORIF with an internal locking plate. Few studies focus on this condition and risk factors remain a discussion topic. Hertel's criteria for initial head ischemia right after fracture (fracture complexity, medial hinge displacement and short metaphyseal head extension) have recently been correlated to HHN, but there is still a clear lack of evidence on the topic. Due to its anatomical similarities to the proximal femur, some authors argue that PHF may as well benefit from early surgery to avoid head necrosis. METHODS: In this 10-year retrospective study, we assessed 305 patients from a single center. All cases were treated with a PHILOS plate through a deltopectoral approach. The mean follow-up time was 467 days. The primary endpoint was HHN. RESULTS: HHN was diagnosed in 12 patients (4%), 10 of which were diagnosed within the first year and one case 4 years after surgery. A positive correlation (p < 0.04) was found between HHN and fracture type (both in AO and Neer's classification), initial neck-shaft-angle (NSA) and metaphyseal head extension (MHE). Medial hinge displacement (MHD) occurred in all HHN cases. Achieving perfect reduction (< 2 mm dislocation) was relevant to avoiding HHN (p = 0.035). Although HHN developed in 32% of the high risk cases (four-part fractures with a short MHE), it was completely avoided (0%) when perfect reduction was achieved. Time until surgery after admission was neither a protective nor a risk factor for HHN. CONCLUSION: We conclude that fracture complexity (four-part and C-fractures) as well as disruption of the medial hinge with a metaphyseal head extension smaller than 8 mm are relevant risk factors for humerus head necrosis. A combination of these criteria generated an high risk pattern with a 32% rate of HHN. Though often difficult to achieve, perfect reduction was a clear protective factor and reduced HHN to 0%. Perfect reduction may be key to inosculation and, therefore, salvage of the humerus head, especially in high risk cases. Surgery timing did not correlate with HHN. LEVEL OF EVIDENCE: Level 3, retrospective cohort study.

Cochlear implantation in a patient with a POU4F3 mutation.

Cochlear implants (CIs) are generally considered useful in the treatment of hereditary hearing loss with progressive deafness. Early CI can be beneficial for maintaining social activities in POU4F3 mutation patients.

Prognostic value of left atrial strain in patients with moderate asymptomatic mitral regurgitation.

For patients with asymptomatic mitral regurgitation (MR), the criteria identifying the groups at higher-risk and their clinical outcome are still uncertain. Therefore, in these patients, optimal time of surgery remains controversial. The purpose of this study was to compare left atrial (LA) strain to other echocardiographic left ventricular (LV) and LA parameters for the prediction of cardiovascular outcomes in patients with moderate asymptomatic MR. We enrolled 395 patients with primary degenerative moderate asymptomatic MR. Exclusion criteria were: history of atrial fibrillation, myocardial infarction, heart failure, cardiac surgery or heart transplantation, severe MR, mitral valve surgery during follow-up. Patients were prospectively followed for 3.5 ± 1.6 years for the development of cardiovascular events i.e. atrial fibrillation, stroke/transient ischaemic attack, acute heart failure, cardiovascular death. Of 276 patients (mean age 66 ± 8 years) who met eligibility criteria, 108 patients had 141 new events. Patients who developed cardiovascular events presented reduced global peak atrial longitudinal strain (PALS), reduced LA emptying fraction, larger LA volume indexed and lower LV strain at baseline (p < 0.0001). With receiving operating characteristics (ROC) curve analysis, global PALS < 35% showed the greatest predictive performance (AUC global PALS: 0.87). Bland-Altman analysis demonstrated good intra- and interobserver agreement with small bias and Kaplan-Meier analysis showed a graded association between PALS and event-free-survival rates. Speckle tracking imaging could provide a useful index, global PALS, to estimate LA function in asymptomatic moderate MR in order to optimize timing of surgery before the development of irreversible myocardial dysfunction.

A Two-decade Assessment of Changing Practice for Surgical Decompression and Fixation after Traumatic Spinal Cord Injury - Impact on Healthcare Utilization and Cost.

Early surgery after traumatic spinal cord injury (TSCI) has been associated with a greater neurological recovery and reduced secondary complications. In this study, we aimed to evaluate the trend of early TSCI surgery (within 24 hours) over two decades and the effect on length of hospitalization, complications, and hospital charges. We extracted emergency admissions of adults diagnosed with TSCI from the National Inpatient Sample database (1998-2016). We analyzed the trend of early surgery and concurrent trends of complication rate, length of stay (LOS) and hospital charges. These outcomes were then compared between early and late surgery cohorts. There were 3942 (53%) TSCI patients who underwent early surgery, and 3446 (47%) were operated after 24 hours. The combined patient group characteristics consisted of median age 43 years (IQR: 29-59), 73% males, 72% white, 44% private payer, 18% Medicare, 17% Medicaid, 51% cervical, 30% thoracic, 75% from large hospitals, and 79% from teaching hospitals. The trend of early surgery, adjusted for annual case-mix, increased from 45% in 1998 to 64% in 2016. Each year was associated with 1.60% more patients undergoing early surgery than the previous year (p-value <0.05). During these years, the total LOS decreased, while hospital charges increased. Patients who underwent early surgery spent four fewer days in the hospital, accrued $28,705 lower in hospital charges and had 2.8% fewer complications than those with delay surgery. We found that the rate of early surgery has significantly increased from 1998 to 2016. However, as of 2016, one-third of patients still did not undergo spinal surgery within 24 hours. Late surgery is associated with higher complications, longer stays, and higher charges. The causes of delayed surgery are undoubtedly justified in some situations but require further delineation. Surgeons should consider performing surgery within 24 hours on patients with TSCI whenever feasible.

Development and validation of a nomogram predicting the probability of type a aortic dissection at a diameter below 55 mm: A retrospective cohort study.

INTRODUCTION: The study aims to build and validate a nomogram for estimating the probability of patients developing type A aortic dissection at a diameter less than 55 mm. METHODS: A primary cohort of 896 patients diagnosed with acute type A aortic dissection by computed tomography angiography (CTA) were used for model development, with data collected between January 2005 and March 2012. The subjects were assigned to two groups based on ascending aorta diameter (group A<55 mm, Group B ≥ 60 mm). Univariate and multivariate logistic regression analyses were employed for the development of the prediction model. Demographic factors, as well as clinical and imaging characteristics were taken into account. The resulting nomogram was evaluated for performance traits, e.g. calibration, discrimination and clinical usefulness. After internal validation, the nomogram was further assessed in a different cohort containing 385 consecutive subjects examined between January 2013 and December 2015. RESULTS: The individualized prediction nomogram included 9 predictors derived from univariate and multivariable analyses, including gender, age, weight, hypertension, liver cyst, renal cyst, bicuspid aortic valve, and bovine arch. Those predictors were double confirmed with Lasso regression. Internal validation showed good discrimination of the model with area under the curve (AUC) of 0.854 and good calibration (Hosmer-Lemeshow test, P = 0.876). Application of the nomogram in the validation cohort still revealed good discrimination (AUC = 0.802) and good calibration (Hosmer-Lemeshow test, P = 0.398). Decision curve analysis demonstrated that the prediction nomogram was clinically useful. CONCLUSIONS: The current work presents a prediction nomogram incorporating demographical data as well as clinical and imaging characteristics that could help identify patients who might develop type A aortic dissection at a diameter less than 55 mm with convenience.

Early (≤48 Hours) versus Late (>48 Hours) Surgery in Spinal Cord Injury: Treatment Outcomes and Risk Factors for Spinal Cord Injury.

OBJECTIVES: Surgical management of spinal cord injury (SCI) is challenging. There is no standard guideline regarding the timing of surgery, although physicians have prioritized early surgery over the past decades. Although better outcomes have been observed from these studies, the definition of early surgery has been controversial, although mostly limited to 24-hours after injury. For some hospitals, this early surgery could be difficult to implement in practice. Hence, we re-evaluated the timing of early surgery as surgery within 48 hours and investigated the surgical outcomes of SCI depending on whether surgery was performed early (≤48 hours) or late (>48 hours). The primary outcomes were improvement in the American Spinal Injury Association Impairment Scale (AIS) grade in early and late surgery groups. METHODS: This study was a retrospective cohort study in individuals aged 15-85 years, who underwent surgery for SCI between 2005 and 2016. The rate of AIS grade improvements was measured at 6 months after injury. Of the 86 enrolled patients, 31 (mean, 40.9 ± 12.64 hours) and 55 (mean, 168.25 ± 93.01 hours) patients were assigned to the early and late surgery groups, respectively. RESULTS: AIS grade improvement was significantly greater in the early than in the late group (P = 0.039). In the early group, there was no significant difference in neurologic improvements among the AIS B, C, and D groups, but the AIS A group showed a significant improvement (P = 0.015). This finding was not observed in the late group (P = 0.060). AIS grade improvement was also significantly greater in the incomplete SCI group than in the complete SCI group, for all measurements (early, P = 0.007, late, P = 0.009). Other factors that significantly affected clinical outcomes were AIS grade on admission and the level of the injury.

When should gallbladder polyps be treated surgically?

BACKGROUND: This study was performed to better understand the best surgery timing for gallbladder polyps (GP). OBJECTIVES: The objective was to determine the potential for malignant transformation and the best timing for surgery in GP, based on an assessment of the clinical symptomatology and on the results of the imaging and histopathological examinations. MATERIAL AND METHODS: Age, gender, clinical symptoms, preoperative ultrasound findings, and the results of the postoperative histopathological examination were retrospectively assessed in a total of 2,656 patients undergoing cholecystectomy in Department of General Surgery, Hitit University School of Medicine, Çorum, Turkey, between 2008 and 2013. RESULTS: From a total of 2,656 patients undergoing cholecystectomy in our unit between 2008 and 2013, 96 subjects were found to have the following types of GP: 66.6% (n = 64) had cholesterol polyps, 13.54% (n = 13) had adenomyomatous polyps, 8.33% (n = 8) had adenocarcinoma, 7.2% (n = 7) had inflammatory polyps, and 4.16% (n = 4) had hyperplastic polyps. Also, 85.4% of these patients (n = 82) had a single polyp only, while 14.6% (n = 14) had 2 polyps. The polyp size in patients with adenocarcinoma was 9 mm, 10 mm and 12 mm in 2, 4 and 2 patients, respectively. The mean age of patients with adenocarcinoma was 60 years (55-74), all of whom had solitary polyps. CONCLUSIONS: In patients over 50 years of age with co-existent cholelithiasis and GP exceeding 10 mm, surgical treatment should be undertaken due to the risk of malignancy. Other patients with polyps less than 10 mm in size should be followed up in 6-month intervals using ultrasound examination.

[Surgical techniques for severe brain injury : With special emphasis on polytrauma]. / Operationstechniken beim Schädel-Hirn-Trauma : Unter besonderer Berücksichtigung des Polytraumas.

CLINICAL ISSUE: In Austria approximately 2000 people suffer from severe brain injury per year. Brain trauma is the most common cause of death under the age of 45 years. In polytrauma patients the treatment and management of severe brain injury is particularly challenging because the life-threatening injuries of other organ systems significantly influence the timing of surgery and the outcome. The sequence of the necessary surgery is an interdisciplinary decision already made in the emergency room. The evacuation of space-occupying intracranial hemorrhage can be of secondary importance. STANDARD TREATMENT: The standard approach for acute subdural hematoma is a craniotomy using a large question mark-shaped incision (trauma flap) and decompression. In acute epidural hematoma and impression fractures the localization of the lesion determines the surgical approach and evacuation. A variety of access procedures are available. Frontobasal injuries are extremely rarely an indication for an emergency operation for life-threatening injuries. Decompressive craniotomy is performed as for craniotomy for acute subdural hematoma by the standard trauma flap. DIAGNOSTIC WORK-UP: Emergency room computed tomography provides fast and accurate information about the localization and extent of brain injury. PERFORMANCE: The mortality of acute subdural hematoma ranges between 50-90% despite an adequate evacuation. Outcome of epidural hematoma has a much better prognosis (10% mortality). The results of decompressive craniectomy versus conservative treatment for moderate disability and good recovery are quite similar according to the randomized evaluation of surgery with craniectomy for uncontrolled elevation of intracranial pressure (RESCUE-ICP) study. PRACTICAL RECOMMENDATION: Interdisciplinary cooperation and communication and well-trained trauma surgeons with experience in brain trauma are key factors in the treatment of severe brain injury in polytrauma patients.

Dynamic intraligamentary stabilization versus conventional ACL reconstruction: A matched study on return to work.

PURPOSE: The dynamic intraligamentary stabilization (DIS) technique is based on a different treatment approach than ACL reconstruction in that it intends to promote self-healing of the ligament. It is only recommended for acute injuries (<21days). The purpose of the present study was to compare DIS and ACLR with respect to the extent of work incapacity, revision rates, secondary arthroscopies, and treatment costs during recovery. METHODS: The study was a post-hoc analysis of prospectively collected data in the Swiss National Accident Insurance Fund (SUVA) database. All registered DIS cases treated until 31 December 2012 were included in the study. ACLR cases were matched to DIS cases using a propensity score approach and analysed in a follow-up period of 2 years after injury. Paired Student's T-test and the Chi-square test were used to compare the outcome measures. RESULTS: All 53 DIS patients were matched to an ACLR pair. The mean time period from injury to surgery was 14days for DIS and 50days for ACLR (p<0.001). Overall work incapacity was 13% for DIS and 17% for ACLR resulting in a difference of nearly 1 month of absence from work (p=0.03). The course of postoperative work incapacity was very similar between the groups, while the work incapacity prior to surgery lower in the DIS group. We found no difference in treatment costs, secondary arthroscopies and revision rates. CONCLUSION: DIS patients benefited from nearly one month shorter absence from work than ACLR patients. This difference is likely related to the early surgical timing that is recommended for DIS. Since no differences were found between DIS and ACLR in terms of treatment costs, secondary arthroscopies and revision rates, the study supports the choice of DIS as an additional treatment option for acute ACL injuries. Further comparative studies are proposed to improve the evidence about optimal timing and best practice in ACL treatment.