.
BACKGROUND:The optimal timing of tracheostomy in critically ill patients remains controversial. While early tracheostomy has been associated with reduced ventilator days and intensive care unit length of stay (LOS), survival benefits remain inconsistent. The coronavirus disease 2019 (COVID-19) pandemic changed intensive care unit workflows, airway management strategies, and interdisciplinary decision-making, potentially affecting tracheostomy practices even beyond the pandemic. AIM:To evaluate differences in tracheostomy timing, interdisciplinary consultation patterns, and clinical outcomes before and after the COVID-19 pandemic in critically ill patients without active COVID-19. METHODS:This is a single-center retrospective cohort study of adult patients undergoing tracheostomy at a community hospital in New York during two periods, pre-COVID (October 2012 to February 2020) and post-COVID (June 2022 to July 2024). Patients with active COVID-19 were excluded. Demographics, comorbidities, time-based outcomes (including time to palliative care and surgical consultation, intubation-to-tracheostomy interval, and hospital LOS), and mortality at 2 months and 6 months were analyzed. Multivariable logistic regression was used to identify factors associated with 6-month mortality. RESULTS:A total of 314 patients were included (246 pre-COVID, 68 post-COVID). Compared with the pre-COVID cohort, post-COVID patients had a significantly shorter time to palliative care consultation (3 days vs 7 days, P = 0.001), surgical consultation (9.5 days vs 15.0 days, P < 0.001), intubation-to-tracheostomy interval (11.0 days vs 15.5 days, P < 0.001), and hospital LOS (29.5 days vs 34.0 days, P = 0.033). Mortality at 2 months and 6 months did not differ significantly between cohorts. In multivariable analyses, age was the only factor independently associated with mortality. CONCLUSION:The post-COVID era was associated with earlier interdisciplinary engagement and tracheostomy placement without improvement in short- or long-term mortality. These findings suggest a pandemic-driven change in airway management practices. The COVID-19 pandemic may have sensitized healthcare providers, leading to earlier involvement in tracheostomy decision-making, but long-term effects are yet to be determined.
Spontaneous posterior rectus sheath/interparietal hernias are exceedingly rare, with only a limited number of case reports published in the literature, particularly in patients without history of prior abdominal surgery. They may present diagnostic difficulty because the herniated bowel can remain contained within the abdominal wall layers without an obvious external bulge. We report a 65-year-old woman with hypertension and asthma, with prior hysterectomy via a transvaginal approach and no prior abdominal surgery, who presented with one day of abdominal pain, nausea, vomiting, and more than 24 hours of obstipation. Laboratory evaluation showed leukocytosis of 13.3×10⁹/L, with otherwise unremarkable chemistry and coagulation studies. CT demonstrated small bowel obstruction secondary to a right upper abdominal wall hernia, with a short segment of small bowel herniating between the transversus abdominis and rectus abdominis muscles, mild upstream dilation, small bowel feces sign, and reactive simple fluid in the hernia sac. Given persistent obstruction despite initial nonoperative management, the patient underwent operative exploration. The incarcerated small bowel was reduced from an obstructed interparietal abdominal wall hernia. The bowel was viable after reduction, and no resection was required. The hernia sac was excised and the fascial defect was closed. This case highlights a rare cause of small bowel obstruction in a virgin part of the abdominal wall and emphasizes the importance of careful CT review for deep abdominal wall hernias.
OBJECTIVES:Metabolic dysfunction-associated steatotic liver disease (MASLD) is common and linked to cardiometabolic comorbidities, with few direct comparisons between glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors (SGLT2is). METHODS:This multicenter, retrospective, propensity score-matched cohort study utilized data from the TriNetX U.S. Collaborative Network. Adults with MASLD and at least one metabolic comorbidity were identified as new initiators of semaglutide (n = 128,332) or SGLT2is (n = 100,542), excluding alternative exposures and confounding liver etiologies. One-to-one propensity score matching on >50 covariates yielded balanced cohorts of 55,525 patients each. Time-to-event outcomes, including all-cause mortality, hospitalization, major adverse cardiovascular events, major adverse liver outcomes, major adverse kidney events, ascites, hepatic failure, and hepatic encephalopathy, were evaluated at 1-year and 5-year follow-ups using Kaplan-Meier analysis and Cox proportional hazards models. RESULTS:Semaglutide was linked to significant risk reductions compared to SGLT2is. At 1-year, hazard ratios (HRs) were 0.382 (95% CI 0.338-0.430) for all-cause mortality, 0.444 (95% CI 0.429-0.459) for all-cause hospitalization, 0.502 (95% CI 0.476-0.530) for major adverse cardiovascular events, and 0.361 (95% CI 0.316-0.412) for major adverse liver outcomes. At 5-years, the corresponding HRs were 0.494 (95% CI 0.459-0.531), 0.565 (95% CI 0.551-0.579), 0.584 (95% CI 0.560-0.609), and 0.494 (95% CI 0.452-0.540). Major adverse kidney events showed no difference at 1-year (HR 0.998), but a reduction at 5-years (HR 0.858; 95% CI 0.789-0.933). Individual liver events (ascites, hepatic failure) followed similar patterns. CONCLUSIONS:In this large real-world MASLD cohort, initiating semaglutide was linked to potential reductions in mortality, hospitalization, and adverse cardiometabolic, liver, and kidney outcomes compared to SGLT2is.
Background/Objectives: The opioid epidemic has increased awareness of inpatient opioid use after surgery. Effective pain control is essential for recovery; however, factors influencing postoperative opioid requirements (PORs) remain unclear. This study examined patient-specific factors and surgical platforms associated with postoperative rescue opioid use within 48 h of bariatric surgery. Methods: A retrospective chart review was conducted on patients undergoing bariatric surgery (Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG)) from March 2021 to March 2023 at a community hospital setting. Data included demographics, comorbidities, psychiatric history, prior surgeries (cholecystectomy, hernia repair, other bariatric surgery), intraoperative parameters, postoperative disposition, hospital length of stay, and PORs measured in morphine milligram equivalents (MME). Robotic and laparoscopic surgery were compared and risk factors for increased PORs were analyzed. Results: Among 442 patients (86.7% women, mean age 42.1 ± 12.0 years), robotic procedures (51.6%) had higher PORs than laparoscopic procedures (13.3 ± 13.2 versus 10.1 ± 11.2 MME; p < 0.01), mainly driven by the SG group (14.8 ± 13.3 versus 9.2 ± 9.6 MME, respectively; p < 0.01). In multivariable logistic regression, robotic surgery (OR 1.38, 95% CI: 1.02-1.88, p = 0.041), psychiatric history (OR 1.67, 95% CI: 1.11-2.51, p = 0.014), and prior surgery (OR 1.52, 95% CI: 1.03-2.24, p = 0.034) were associated with increased PORs (>10 MME). No significant differences were observed based on sex, type of procedure (SG vs. RYGB), or body mass index. Conclusions: In this study, robotic surgery was associated with higher PORs. Preoperative psychiatric evaluation and multimodal pain management strategies may assist in the optimization of analgesia in patients with psychiatric conditions or prior surgery.
Nonalcoholic fatty liver disease (now termed metabolic dysfunction-associated steatotic liver disease [MASLD]) is a leading cause of liver-related mortality worldwide, linked to the rising prevalence of metabolic syndrome. Despite prior analyses using earlier Global Burden of Disease (GBD) iterations, comprehensive trends incorporating post-2020 data remain limited. This study provides the first analysis utilizing the latest GBD 2023 release, examining global, sex-, and country-specific disparities in MASLD age-standardized mortality rates (ASMR) from 1990 to 2023 across 204 countries, highlighting the impact of recent events like the COVID-19 pandemic on metabolic health. MASLD ASMR data were extracted from the GBD 2023 database, defined by International Classification of Diseases, 10th Revision codes. Estimated annual percentage changes (EAPC) in ASMR were calculated using logarithmic linear regression. Analyses were stratified by sex and country, with 95% confidence intervals derived from the standard error of β. Globally, the mean EAPC was 0.152% (range: -3.079% in the Republic of Korea to 4.143% in Kazakhstan) for both sexes, 0.020% for females (-3.630% in Bermuda to 4.612% in the Russian Federation), and 0.291% for males (-2.970% in the Republic of Korea to 4.277% in Turkmenistan). Increases predominated in 111 countries (54.4%), with significance in 94; declines in 93, significant in 78. Pronounced rises occurred in Eastern Europe/Central Asia (e.g., Kazakhstan, Russian Federation) and the Middle East (e.g., Oman), while declines were evident in East Asia (e.g., the Republic of Korea) and Southern Europe (e.g., Italy). Males showed higher EAPC in 119 countries, with a mean sex difference of 0.271%; notable disparities included Cuba (males 3.296% vs females -0.172%). Country-specific trends revealed vulnerabilities in low- and middle-income countries, with mixed patterns in Africa. This inaugural GBD 2023 analysis reveals a modest global rise in MASLD mortality, with regional surges in transitioning economies and male-predominant disparities. Urgent, tailored interventions targeting metabolic risks are essential to mitigate this escalating burden.
