Background: Frailty is a multidimensional clinical syndrome characterized by reduced physiological reserve and increased vulnerability to surgical stress. Conventional perioperative risk assessment based on chronological age and comorbidity burden may inadequately reflect biological vulnerability in patients undergoing major digestive surgery. The Frailty Index (FI) provides a comprehensive measure of frailty; however, prospective evidence evaluating its association with short-term postoperative outcomes remains limited. Methods: This prospective cohort study, reported in accordance with the STROCSS 2025 guidelines, included 45 consecutive adults undergoing elective or emergency major digestive surgery at IRCS Hospital, Baghdad, Iraq between January 2024 and December 2025. Preoperative frailty was assessed using a 20-deficit accumulation FI. Patients were classified as non-frail (FI < 0.15), pre-frail (FI: 0.15–0.24), or frail (FI ≥ 0.25). The primary outcomes were postoperative complications (Clavien–Dindo grade ≥II), postoperative length of hospital stay, and 30-day all-cause mortality. Postoperative intensive care unit (ICU) admission was a secondary outcome. Multivariable logistic regression was used to evaluate the associations between frailty status and postoperative complications, adjusting for age, American Society of Anesthesiologists (ASA) physical status, and surgical urgency. Results: Eighteen patients (40.0%) were non-frail, 15 (33.3%) were pre-frail, and 12 (26.7%) were frail. Postoperative complications occurred in 16.7%, 33.3%, and 66.7% of patients, respectively ( P = 0.023). Median postoperative length of hospital stay increased from 6 to 9 to 14 days across the three frailty categories ( P < 0.001). ICU admission occurred in 11.1%, 26.7%, and 58.3% of patients, respectively ( P = 0.024). Thirty-day mortality occurred only among frail patients (2/12, 16.7%), although the overall between-group difference was not statistically significant ( P = 0.067). After multivariable adjustment, pre-frailty [adjusted odds ratio (aOR): 2.40, 95% confidence interval (CI): 1.10–5.20; P = 0.041] and frailty (aOR: 6.90, 95% CI: 2.30–20.40; P < 0.001) were independently associated with postoperative complications. Conclusions: Preoperative frailty was independently associated with higher odds of postoperative complications and was also associated with adverse short-term postoperative outcomes following major digestive surgery. Routine preoperative frailty assessment may contribute to perioperative risk stratification and facilitate targeted perioperative optimization. Larger multicenter prospective studies are warranted to validate these exploratory findings.
Diabetic kidney disease carries residual cardiorenal risk despite renin-angiotensin system blockade. Combination effect of Finerenone and Empagliflozin in participants with chronic kidney disease and type 2 diabetes using a urinary albumin-to-creatinine ratio Endpoint showed that simultaneous finerenone and the sodium-glucose cotransporter 2 inhibitor empagliflozin reduced urinary albumin-to-creatinine ratio by 52%, compared with 32% with finerenone and 29% with empagliflozin. Adverse events leading to discontinuation were uncommon. However, the trial used a surrogate endpoint, was limited to 180 days of follow-up, and excluded patients with estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m 2 or potassium above 4.8 mmol/L. This editorial examines the implications of these limitations for patient selection, timing, and safety monitoring, and proposes a risk-readiness-reassessment framework. Cardiorenal risk determines the urgency of combination therapy; readiness determines whether treatment should be initiated simultaneously or staged over 2–4 weeks; and reassessment distinguishes expected changes from clinically important harm. Simultaneous initiation may be reasonable when potassium, eGFR, blood pressure, volume status, and monitoring access are favorable. Rapid staged initiation may be preferable when these factors create diagnostic or safety uncertainty. The framework requires prospective validation. The objective should be timely, sustainable complementary therapy rather than same-day initiation in every eligible patient.
Introduction and importance: Adult-onset Still’s disease (AOSD) is a multisystem autoinflammatory disorder with diverse clinical manifestations. Diagnosis may be challenging, particularly in the absence of the characteristic rash, and when complicated by macrophage activation syndrome (MAS). Case presentation: A 50-year-old Ethiopian woman presented with recurrent high-grade fever, diffuse arthralgia, myalgia, constitutional symptoms, and persistent systemic inflammation. Extensive infectious, autoimmune, and malignant evaluations were unrevealing. Laboratory investigations demonstrated neutrophilic leukocytosis, elevated inflammatory markers, marked hyperferritinemia, thrombocytopenia, mild transaminitis, and hypertriglyceridemia. The patient additionally developed hypoxemia, with pleural effusions and radiologic features suggestive of pulmonary hypertension. Despite the absence of the typical rash and lack of hemophagocytosis on bone marrow examination, AOSD, complicated by evolving MAS, was diagnosed based on clinical and laboratory findings after exclusion of alternative etiologies. The patient demonstrated marked clinical and biochemical improvement following escalation to high-dose corticosteroid therapy. Clinical discussion: This case underscores the diagnostic difficulty of diagnosing AOSD when the characteristic rash is absent and highlights the importance of recognizing an evolving MAS in patients with persistent systemic inflammation, cytopenias, and marked hyperferritinemia, even in the absence of bone marrow hemophagocytosis. Conclusion: AOSD should be considered in patients with unexplained, persistent fever and systemic inflammation, even when the characteristic rash is absent. Evolving MAS can occur despite the absence of hemophagocytosis on bone marrow examination, and early recognition with prompt initiation of immunosuppressive therapy is essential to improve outcomes.
Background and objectives: Alveolar ridge preservation (ARP) mitigates post-extraction bone loss to facilitate implant placement, yet many ARP methods rely on grafts or membranes. Simple, cost-effective alternatives harnessing innate healing are needed. Socket decortication – intentional perforation of the cortical wall – may enhance vascular and cellular supply to promote bone formation. This split-mouth randomized controlled trial compared dimensional changes following mandibular molar extraction between sites treated with lingual plate decortication and contralateral controls healing naturally. Methods: Twenty systemically healthy, non-smoking patients who required extraction of two contralateral mandibular molars with intact sockets were enrolled. One socket was randomly assigned to lingual plate decortication (1.0 mm round bur), and the contralateral socket healed naturally. The primary outcome was the change in alveolar ridge dimensions from baseline to 3 months, assessed by cone-beam computed tomography . A blinded radiologist measured ridge width at four levels (1, 3, 5, and 7 mm) and plate heights. Changes were compared using paired t -tests. Results: All 20 patients (40 sockets) completed follow-up. The decortication group showed significantly less horizontal bone resorption at all measured levels. The most pronounced preservation was at the 1 mm level: − 1.2 ± 0.7 mm for decortication versus −2.8 ± 0.9 mm for control ( P < 0.001). Vertical bone loss trends did not reach significance. All sites healed uneventfully, with no complications. Conclusions: Socket decortication is an effective, safe, graft-free technique for preserving horizontal ridge dimensions in intact mandibular molar sockets at 3 months, offering a simple and cost-effective method for future prosthetic rehabilitation.
