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Total anorectal reconstruction (TAR) can be challenging for surgeons aiming to achieve both anatomic and functional anal reconstruction. Techniques involving coloplasties and graciloplasties have been described but have yet to become routine procedures. In this report, we present a rare case of TAR combining a coloplasty with an innervated gracilis muscle flap. This case aims to illustrate the surgical approach and emphasize the critical role of physiotherapy in postoperative functional recovery. We report the case of a young female patient who underwent abdominoperineal resection (APER) following a low rectal carcinoma, resulting in a permanent end colostomy. Five years later, with no evidence of local or distant recurrence, the patient sought to improve her quality of life. TAR was performed by mobilizing the colon into the perineum and creating a neosphincter through an innervated gracilis muscle flap loop around the colon. Postoperatively, the patient underwent 6 months of intensive pelvic floor rehabilitation, including manometry-guided biofeedback therapy. This case report was prepared in accordance with the CARE (CAse REport) guidelines. Minor revision surgeries were needed to optimize the perineal colostomy scar, and three dilatation procedures were performed over 4 years to manage mild stenosis. The neo-anus remains functional at the 5-year postoperative visit, with fecal continence achieved within 2 months. TAR is documented in the literature, though still not used systematically for various reasons, including inadequate muscle contraction, fatigability, and lack of neuroplastic adaptations in the central nervous system. Through this report, we demonstrate that an adequate surgical technique, followed by intensive pelvic floor training and manometry-assisted biofeedback to promote neuroplasticity, can provide successful outcomes.
Physicians rely on guidelines derived from randomized controlled trials (RCTs) to determine whether interventions are safe and effective for specific diseases or causal mechanisms. In critical care, however, well-powered RCTs demonstrating clear evidence of benefit and subsequently incorporated into clinical guidelines have repeatedly been abandoned after causing harm. This strong evidence of benefit from robust RCTs or meta-analyses followed by unexpected harm during clinical application, generates an “evidence deployment paradox”, which has been attributed to unavoidable biological heterogeneity rather than to structural flaws in trial design. Recent analysis has shifted attention to the architecture of the RCT itself, indicating that the paradox arises from a mathematical set-mixing problem introduced by a modification of the original RCT model when the field adopted a trial design in which enrollment was decoupled from causal diagnosis or the targeted causal mechanism and replaced by consensus-derived, disease- and cause-agnostic triage thresholds. The triage selects broadly shifting mixtures of diseases with potentially different treatment effects. We term this design the cause-agnostic randomized controlled trial. Although cause-agnostic RCT can generate internally valid estimates within trial participants, their results may paradoxically be unsafe to incorporate into clinical guidelines, even when applied in the same hospitals and using the same entry criteria as the source trials. Structural causal modeling provides tools to mitigate this evidence-deployment paradox. Such modeling makes explicit the causal assumptions underlying enrollment and can identify when, and to what extent, a trial has deviated from cause-and-effect logic of the original randomized trial design.
Background: Diabetic peripheral neuropathy (DPN) is a common complication of type 2 diabetes mellitus (T2DM), and hypomagnesemia is a common occurrence in diabetes patients and is suggested to be involved in the development of neuropathy. However, studies have shown conflicting data on the association of serum Mg and DPN. Objective: To determine the prevelance of hypomagnesemia in type 2 diabetic patients and to compare the frequency of peripheral neuropathy in cases with and without hypomagnesemia. Methods: This was a Cross-sectional Study that was carried out at Medicine department of Hameed Latif Hospital, Lahore, from April 2026 to July 2026. A total of 151 patients with T2DM (age 40-65 years and duration of diabetes ≥ 1 year) were included. Serum magnesium was determined and magnesium levels <1.6 mg/dL were considered hypomagnesemia. The Michigan Neuropathy Screening Instrument (MNSI) was used to evaluate peripheral neuropathy. Data analysis was done using SPSS version 26. Chi-squares were used to compare categorical variables, and a p value of <0.05 was considered statistically significant. Results: 43 patients (28.5%) had hypomagnesemia. Peripheral neuropathy was present in 29 (67.4%) hypomagnesemic patients as opposed to 34 (31.5%) patients with normal Mg (χ²=16.82, p<0.001). The mean serum magnesium level was significantly decreased in the neuropathy group compared with the non-neuropathy group (1.52±0.21mg/dL vs 1.89±0.28mg/dL, p<0.001). This association remained after stratification by age, gender and duration of diabetes. Conclusion: Hypomagnesemia was commonly associated with diabetic patients with T2DM, and was significantly associated with the presence of peripheral neuropathy. Measurement of serum magnesium levels could be used to identify at risk diabetic patients for neuropathic complications.
ABSTRACT BACKGROUND Chronic coronary syndromes (CCS) remain under-characterized in Latin America, where clinical profiles may differ from high-income countries. OBJECTIVE We aim to characterize the clinical presentation, coronary anatomic profile, and pharmacologic treatment patterns of adults living with CCS using data from the Mexican Chronic Coronary Syndrome Registry (RESINCCRO). METHODS RESINCCRO is an observational, multicenter, cross-sectional registry conducted across ∼50 centers in five regions from Mexico. We included adults (≥18 years) enrolled between September 2024 and March 2025 who met 2019 ESC CCS criteria. Coronary imaging data was collected from medical records into a standardized electronic case report form. RESULTS We enrolled 3,029 adults (men [72.5%]; mean age 67.2 ± 10.7 years). Cardiometabolic comorbidities were frequent: overweight/obesity (76%), arterial hypertension (69.0%), type 2 diabetes (44.0%), and chronic kidney disease (24.2%). Persistent angina/equivalents occurred in (23.9%), of which most had Canadian Cardiovascular Society class I–II (91.2%). The mean LVEF was of 53.7% ± 12.0. Cardiac rehabilitation participation was (6.2%). Median LDL-C was 70 mg/dL (IQR 51–95) and LDL <55 mg/dL was only 26.1%, despite high prescription of lipid-lowering therapies, including statins (93.2%), ezetimibe (24.6%), and PCSK9 inhibitors (2.4%). 60.3% had obstructive epicardial disease. CONCLUSIONS Mexican adults with CCS exhibit high cardiometabolic burden, frequent symptoms, suboptimal LDL-C goal attainment, low rehabilitation uptake, and a substantial obstructive phenotype. These findings highlight opportunities to intensify secondary prevention, adopt mechanism-directed evaluation and therapy, and expand cardiac rehabilitation to improve CCS care in Mexico.
