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Background One of the most prevalent sleep disorders affecting the individual’s daily life is obstructive sleep apnea (OSA), for which obesity is a major risk factor. Several novel lipid indices have been suggested to have associations with OSA, among which visceral adiposity index (VAI), atherogenic index of plasma (AIP), and lipid accumulation product (LAP) are the most important ones. Herein, the current study aimed to systematically investigate the association between these indices and OSA. Methods Four international databases, including PubMed, Scopus, the Web of Science, and Embase were searched in order to find relevant studies that investigated LAP, VAI, or AIP in OSA and compared them with non-OSA cases or within different severities of OSA. Random-effect meta-analysis was used to generate the standardized mean difference (SMD) and 95% confidence interval (CI) of the difference in lipid indices between OSA and non-OSA cases. Moreover, the pooled area under the receiver operating characteristic curves (AUCs) observed in individual studies for diagnosis of OSA based on these lipid indices were calculated by random-effect meta-analysis. Results Totally 14 original studies were included, comprised of 14,943 cases. AIP, LAP, and VAI were assessed in eight, five, and five studies, respectively. Overall, these lipid indices had acceptable diagnostic ability (AUC 0.70, 95% CI 0.67 to 073). Meta-analysis revealed that AIP was significantly higher in patients with OSA (SMD 0.71, 95% CI 0.45 to 0.97, P  < 0.01). Moreover, AIP also increased in higher severities of OSA. Regarding LAP, a higher LAP was observed in OSA/patients with high risk for OSA rather than in controls/low risk for OSA (SMD 0.53, 95% CI 0.25 to 0.81, P  < 0.01). VAI was also increased in OSA based on results from two studies. Conclusion These findings suggest that composite lipid indices are increased in OSA. Also, these indices can have the potential beneficiary diagnostic and prognostic ability in OSA. Future studies can confirm these findings and enlighten the role of lipid indices in OSA.

Background and Aims The Hemorrhoidal Disease Symptom Score (HDSS) is a tool that is scored based on five main symptoms: pain, bleeding, itching, soiling, and prolapse. Furthermore, the Short Health Scale (SHS) is a measurement tool of subjective health and health‐related quality of life. This study was performed to validate the Farsi‐translated Hemorrhoidal Disease Symptom Score (HDSS), and Scale Short Health Scale adapted for hemorrhoidal disease (SHS‐HD) as a measure of symptom severity in patients with hemorrhoid disease. Methods In this study, HDSS and SHS‐HD were translated into Farsi. Participants with confirmed hemorrhoid disease completed the questionnaire. Subsequently, the questionnaire's discriminative validity, convergent validity, reliability, sensitivity, and specificity were evaluated. Results Data from 31 patients were analyzed (mean age 39.68; 71% male). The results of the analysis showed good internal consistency as Cronbach's α for HDSS and SHS were 0.994 and 0.995 respectively. Spearman's correlation coefficient for the test–retest comparison was 0.986 (p < 0.01). The responses demonstrated good convergent validity. Moreover, the comprehension and suitability of each question were rated as excellent (Pearson's correlation coefficient = 0.3). Conclusions Our findings revealed that the Farsi translation of the HDSS and SHS‐HD can be a valuable tool for evaluating the symptom severity in patients with hemorrhoid disease.

Background Leiomyomas are benign smooth muscle tumors found at the gastroesophageal junction (GEJ) ( Mathew G, Osueni A, Carter YM. Esophageal Leiomyoma. StatPearls. StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC; 2024.). Traditional management often involves total gastrectomy with esophagojejunostomy, a highly morbid procedure that impacts quality of life ( Teh JL, Shabbir A. Resection of Gastroesophageal Junction Submucosal Tumors (SMTs). In: Lomanto D, Chen WT-L, Fuentes MB (eds). Mastering Endo-Laparoscopic and Thoracoscopic Surgery: ELSA Manual. Springer Nature Singapore; 2023. pp. 207-211.). We present a case of a large endophytic GEJ leiomyoma managed with robotic-assisted endoluminal mass resection and transoral specimen extraction. Methods A 46-year-old female with upper abdominal pain was diagnosed with a 9×3 cm lobular leiomyoma at the GEJ via computed tomography and endoscopic biopsy. The tumor was excised using the da Vinci Xi system, with transgastric endoluminal trocar placement. The GEJ defect was closed over a gastroscope, allowing visualization and continuous insufflation. Results Complete resection was achieved without creating a full-thickness defect. The mass was retrieved transorally with an endoscope, and the defect was repaired to minimize the risk of stenosis. The procedure lasted 236 min with minimal blood loss (150 mL) and with no complications. Pathology confirmed leiomyoma with negative margins. The patient was discharged on postoperative day 4 on a full liquid diet, requiring no narcotics, and was later advanced to a regular diet. No complications, readmissions, or mortality were reported at the 7-month follow-up. Conclusions Robotic-assisted endoluminal GEJ mass resection is a feasible, safe technique for large benign tumors, preserving the stomach and GEJ, and thereby obviating lifestyle changes from total gastrectomy. It minimizes the risk of anastomotic leak, stricture, vagus nerve injury, gastroparesis, and reflux (Levine et al. AJR Am J Roentgenol. 157:1189–1194). Closure of the GEJ defect using an endoscope allows for adequate insufflation of the proximal stomach. When feasible, combining transoral specimen extraction enhances the benefits of this minimally invasive approach (Yin et al. Chin Clin Oncol. 13:6).

Current pharmacological treatments against post-traumatic stress disorder (PTSD) lack adequate efficacy. As a result, intense research has focused on identifying other molecular pathways mediating the pathogenesis of this condition. One such pathway is neuroinflammation, which has demonstrated a role in PTSD pathogenesis by causing synaptic dysfunction, neuronal death, and functional impairment in the hippocampus. Phosphodiesterase (PDE) inhibitors (PDEIs) have emerged as promising therapeutic agents against neuroinflammation in other neurological conditions. Furthermore, PDEIs have shown some promise in animal models of PTSD. However, the current model of PTSD pathogenesis, which is based on dysregulated fear learning, implies that PDE inhibition in neurons should enhance the acquisition of fear memory from the traumatic event. As a result, we hypothesized that PDEIs may improve PTSD symptoms through inhibiting neuroinflammation rather than long-term potentiation-related mechanisms. To this end, we tested the therapeutic efficacy of cilostazol, a selective inhibitor of PDE3, on PTSD-related anxiety symptoms in the underwater trauma model of PTSD. PDE3 is expressed much more richly in microglia and astrocytes compared to neurons in the murine brain. Furthermore, we used hippocampal indolamine 2,3-dioxygenase 1 (IDO) expression and interleukin 1 beta (IL-1β) concentration as indicators of neuroinflammation. We observed that cilostazol pretreatment prevented the development of anxiety symptoms and the increase in hippocampal IDO and IL-1β following PTSD induction. As a result, PDE3 inhibition ameliorated the neuroinflammatory processes involved in the development of PTSD symptoms. Therefore, cilostazol and other PDEIs may be promising candidates for further investigation as pharmacological therapies against PTSD.

BackgroundSurgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability.MethodsOur survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts.ResultsWe received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes.ConclusionSurgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons’ attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice.

Objective Hypertensive disorders during pregnancy are a significant cause of maternal and perinatal mortality and morbidity worldwide. White coat hypertension (WCH) is a hypertensive disease characterized by an increased clinic blood pressure but normal home or workplace blood pressure. Due to variable prevalence, a subset of women with WCH may be incorrectly diagnosed with chronic hypertension, highlighting the need for accurate diagnosis. Little is known about the role of WCH in pregnancy, but a meta-analysis aims to determine whether WCH increases the likelihood of developing preeclampsia. Methods A systematic review and meta-analysis was conducted to determine whether there is an association between WCH and the incidence of preeclampsia in pregnant women. The search included PubMed, Embase, and Scopus databases until February 2023, using PRISMA guidelines. Pregnant women with apparent office hypertension throughout pregnancy who underwent 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring were included. Meta-analysis was performed using RevMan. Results This study included 12 studies with a total of 4,672 pregnant women and found that women with WCH have a higher risk of developing preeclampsia compared to normotensive women (RR: 2.29, 95% CI [1.18,4.43], P = 0.01). However, when compared with pregnant women with gestational hypertension or chronic hypertension, women with WCH had a significantly lower risk of developing preeclampsia ((RR: 0.39, [0.20,0.80], p=0.009) and (RR: 0.41, [0.27,0.62], P<0.001), respectively). Conclusion The study recommends incorporating 24-hour ABPM into clinical practice to differentiate between chronic hypertension and WCH in early pregnancy and focus on special management for those who need it. The findings may guide future research on ABPM's role in diagnosing WCH and its effects on pregnancy outcomes.

Introduction: While there is an increasing shift towards minimally invasive distal pancreatectomy (MIDP), little is known about how utilization of MIDP vs. open distal pancreatectomy (ODP) has evolved over time. We aimed to determine competing temporal trends in use and outcomes of MIDP (laparoscopic and robotic) over time and to determine if a threshold of effectiveness has been reached. Methods: Adults undergoing MIDP and ODP were identified from the National Cancer Database (2010–2021) and the National Surgical Quality Improvement Program database (2014–2022). Propensity score matching (PSM) was performed to address baseline differences between groups before comparing outcomes. Joinpoint regression analysis (JRA) was employed to assess adjusted trends in adoption and outcomes. We calculated Annual Percentage Change (APC) and Average Annual Percentage Change (AAPC) to quantify yearly adoption rates and their trends, respectively. Results: Among 21,966 patients in the NCDB cohort, 49.5% underwent MIDP, including 33.7% laparoscopic distal pancreatectomy (LDP) and 15.8% robotic distal pancreatectomy (RDP), while 50.5% underwent ODP. ODP declined from 74.1% of cases (2010) to 41.1% (2021), with an AAPC of −4.9%. MIDP increased significantly throughout the study from 25.9% of cases (2010) to 58.9% (2021), with an AAPC of 6.3%. Among MIDP subgroups, there was an initial increase in LDP until 2016, after which its rate of utilization stagnated with an AAPC of 0.7% (p > 0.05). In contrast, RDP demonstrated steady growth with an AAPC of about 15% (p < 0.05). A consistent and significant decline in clinically relevant postoperative pancreatic fistula rates occurred across all surgical approaches, with the most pronounced improvement observed in the robotic approach. MIDP approaches had significantly shorter hospital stays and lower mortality rates; however, RDP cases were associated with longer operative times compared to LDP and ODP. Conclusions: Over the past decade, the use of MIDP increased while ODP decreased. This increase was initially driven by greater use of LDP, which plateaued after 2016, and was further driven by the increased use of the robotic approach. Specifically, RDP demonstrated consistent growth, while LDP showed a decline around 2016. These findings highlight changing practice patterns, accompanied by improvements across all surgical approaches. This may provide insights for clinical training and resource allocation.

(1) Background: Comprehensive evaluation of guideline-concordant care (GCC) across all PDAC stages has yet to be thoroughly conducted. This study aimed to characterize treatment patterns and assess factors associated with receiving GCC among patients with pancreatic ductal adenocarcinoma (PDAC) in California. (2) Methods: Data on adult patients with PDAC were extracted from the California Cancer Registry (2004–2020). GCC is defined according to the recommendations provided by the National Comprehensive Cancer Network. We used multivariable logistic regression to identify factors associated with receiving GCC. A Cox model was used to examine the association of GCC with overall survival. (3) Results: A total of 50,346 PDAC patients were included (stage 1: 10%; stage 2: 25%; stage 3: 11%; stage 4: 54%). Only 46.7% of all patients received GCC (stage 1: 20%; stage 2: 40%; stage 3: 69%; stage 4: 50%). Only 31% of stage 1 patients underwent surgery. Factors inversely associated with receiving GCC were Hispanic ethnicity (OR 0.78; p < 0.001), Black race (OR 0.74; p < 0.001), having no insurance (OR 0.40; p < 0.001]), and a Charlson–Deyo score of ≥2 (OR 0.68; p < 0.001). Adherence to GCC was associated with improved survival (Hazard Ratio 0.39; p < 0.001). Notably, patients with stage 1 PDAC who received GCC had a median survival of 47 months vs. 8 months for those who did not. (4) Conclusions: Although stage 1 PDAC patients have the greatest potential for survival with GCC, only 20% of patients received such treatment. Thus, it is crucial to identify and address the modifiable factors contributing to these suboptimal care patterns.

Anastomotic leakage is one of the major complications of colorectal surgery, which might lead to reoperation, increased hospital stays, further intervention and mortality. Vacuum-assisted closure by devices such as Endo-SPONGE® produced by (B-Braun Medical B.V.) is currently being used to treat leakage and fistula. In this study, we aimed to assess the handmade vacuum-assisted sponge drain for anastomotic leakage following low anterior resection. This prospective study included 22 patients who had undergone sponge drain placement to treat anastomotic leakage. All patients had anastomotic leaks or defects after left anterior rectal resection (LAR) without ileostomy. They were treated with neo-adjuvant chemotherapy before the surgery and then subjected to rigid recto-sigmoidoscopy for 30 days following the operation. Any sign of leakage, such as perianal and pelvic pain, was immediately identified and followed up with a CT scan and another recto-sigmoidoscopy. Twenty-two patients were enrolled in this study, 12 men (54.5%) and 10 women (47.4%). All patients had received neo-adjuvant chemotherapy with an average follow-up of 22.30 ± 3.81. 75% of patients (15 cases) were successfully treated, and 17 patients (85%) underwent successful ostomy closure. Treatment failed in 5 patients (25%), including three men and two women. This study shows that handmade vacuum-assisted sponge drain is a cost-effective method of anastomotic leakage management with efficacy similar to that of Endo-SPONGE ® . Graphical abstract