Annals of Medicine and Surgery最新文献

Background: Acute meningitis is a life-threatening neurological emergency with substantial global morbidity and mortality. Adjunctive corticosteroid therapy aims to mitigate the inflammatory response and improve clinical outcomes.

Methods: We analyzed data from randomized controlled trials, meta-analyses, Cochrane reviews, and international guidelines (e.g., WHO, IDSA, NICE), integrating findings from high-income and resource-limited settings. Key outcomes assessed include mortality, neurological sequelae (e.g., hearing loss, hydrocephalus), length of hospital stay, and treatment-related adverse events.

Results: Corticosteroids significantly reduce mortality and neurological sequelae in acute bacterial meningitis (particularly pneumococcal), especially when administered before or with antibiotics. In tuberculous meningitis, steroids (dexamethasone or prednisolone) improve survival by 25%-30%, though long-term neurological outcomes remain inconsistent. In contrast, viral meningitis shows no clear benefit, and steroids are contraindicated in cryptococcal meningitis due to increased adverse events and worse outcomes. Limited evidence supports steroid use in parasitic meningitis (e.g., Angiostrongylus cantonensis) and non-infectious meningitis (e.g., neurosarcoidosis), where they reduce inflammation and symptom burden. Neonatal meningitis lacks sufficient evidence to support routine corticosteroid use due to potential harms.

Conclusion: Adjunctive corticosteroids are a valuable intervention in specific forms of meningitis, particularly bacterial and tuberculous types, where they improve survival and reduce complications. Their use must be tailored to the etiology, timing, and patient population to avoid harm. Global and regional guidelines recommend dexamethasone as part of initial empiric therapy in suspected bacterial meningitis (excluding neonates), and in all cases of TB meningitis.

Background: Transradial artery access (TRA) is the favored approach for percutaneous coronary intervention (PCI) and coronary angiography (CAG). However, transulnar artery access (TUA) has emerged as an alternative, particularly when TRA is not feasible. This systematic review and meta-analysis aims to compare the efficacy and safety of TUA versus TRA in patients undergoing PCI and CAG.

Methods: From inception to August 2025, a systematic search of electronic databases was conducted. Data were synthesized using a random-effects model, and heterogeneity was assessed using the I ² statistic.

Results: Nine RCTs involving 6089 patients were included. Meta-analysis revealed no significant difference in procedural success between TUA and TRA (RR: 0.93, 95% CI: 0.82-1.06, P = 0.28, I ² = 99%). Similarly, puncture success rates were comparable (RR: 0.95, 95% CI: 0.91-1.00, P = 0.06, I ² = 83%). Secondary outcomes showed no significant differences in puncture attempts or hematoma incidence, but TRA was associated with a shorter procedure time (MD: 0.89, 95% CI: 0.27-1.50, P = 0.005).

Conclusion: TUA provides a viable alternative to TRA, with similar success rates and complication profiles. However, TRA remains superior in terms of procedure time. Further large-scale RCTs are warranted to confirm these findings and refine clinical guidelines.

Pioglitazone, a thiazolidinedione, acts through peroxisome proliferator-activated receptor gamma (PPAR-gamma) and is an established insulin sensitizer used in type 2 diabetes. Many cardio-protective aspects of pioglitazone are being actively researched. The drug modulates neurohormonal pathways and improves diastolic dysfunction in hypertensive patients. In diabetic patients, pioglitazone has been shown to reduce hyperperfusion injury post-STEMI. It also exerts positive effects on cardiac and vascular remodeling. Despite its cardioprotective effects, studies have shown that weight gain and oedema are among the most serious implications of the drug, specifically limiting its role in patients with heart failure. Hence, further studies are required to demonstrate the effect of pioglitazone among patients with heart failure.

Large 2025 adolescent cohorts combining high-resolution MRI with epigenomic profiling now demonstrate that excessive social-media exposure correlates with early cortical thinning signals, neuroinflammatory promoter activation, and impaired attention-executive network maturation. These effects are linked to microglial cytokine priming and activity-dependent chromatin stress rather than structural neurodevelopmental disorders. Emerging data suggest modifiable risk windows through behavioral restriction modeling and inflammation-calming drug-neutral adjuncts without disrupting digital literacy frameworks.

Background: Enhanced recovery after surgery (ERAS) is a protocol aimed at improving surgical outcomes, reducing hospital stay, and lowering costs. This study assessed Sudanese doctors' knowledge, attitudes, and practices regarding ERAS protocols and gathered data to support future implementation in Sudan.

Methods: A cross-sectional study using a validated questionnaire was conducted among Sudanese surgeons in six cities. Data were collected from 492 participants. The analysis involved Cox and Snell R-squared, Nagelkerke R-squared, and Hosmer-Lemeshow goodness-of-fit tests.

Results: Findings showed that 62% of participants had limited knowledge, and 58.1% had limited practice. Additionally, 38.8% were unfamiliar with ERAS guidelines, and 87.2% had not received formal training. A total of 81.7% wrongly believed that mechanical bowel preparation was routinely recommended, and only 33.1% possessed correct knowledge of fasting guidelines. Only 28.9% regularly applied the ERAS protocol. Most respondents (80.3%) believed ERAS improved surgical outcomes, reflecting positive attitudes toward adoption.

Conclusion: This study highlights gaps in knowledge and practice among Sudanese surgeons regarding ERAS protocols, despite positive attitudes toward adoption. Addressing these gaps and progressing toward full implementation is vital for improving operative care in Sudan.

Introduction and importance: While cefepime-induced neurotoxicity is a known complication of beta-lactam therapy in renal impairment, its diagnosis is uniquely challenging in patients with complex neurosurgical baselines. This case illustrates the risk of diagnostic anchoring where the presence of a ventriculoperitoneal shunt diverts clinical suspicion toward mechanical failure and obscures a reversible toxic etiology.

Case presentation: A 63-year-old female with subarachnoid hemorrhage, slit ventricle syndrome, and a ventriculoperitoneal shunt presented with septic shock and acute kidney injury. Following renal adjustment of cefepime for Pseudomonas bacteremia, she developed profound altered mental status. Initial evaluation prioritized shunt malfunction, yet computed tomography was confounded by chronic slit ventricle physiology. Electroencephalography revealed generalized triphasic waves characteristic of metabolic encephalopathy rather than structural dysfunction.

Clinical discussion: Cefepime-induced neurotoxicity (CIN) pathophysiology involves gamma-aminobutyric acid-A receptor inhibition amplified by reduced renal clearance and sepsis-induced blood-brain barrier disruption. Here, the clinical picture was masked by the overlap between toxic encephalopathy and insidious shunt failure symptoms. This necessitated distinguishing toxicity from nonconvulsive status epilepticus or hydrocephalus using electroencephalogram (EEG), defying the heuristic that neurological decline in shunted patients is mechanical until proven otherwise.

Conclusion: This case underscores that CIN can mimic mechanical shunt failure, which necessitates a high index of suspicion in patients with indwelling neurosurgical hardware. Early EEG utilization is critical to overcome diagnostic bias and ensure prompt antibiotic discontinuation rather than unnecessary neurosurgical intervention.

Lung cancer remains a leading cause of cancer-related mortality worldwide, with a pathogenesis deeply influenced by the tumor microenvironment. Two central and interrelated factors -hypoxia and oxidative stress - contribute significantly to tumor progression, angiogenesis, metabolic reprogramming, and therapeutic resistance. In recent years, hydrogen sulfide (H₂S), traditionally viewed as a toxic gas, has gained recognition as a critical gasotransmitter with a regulatory role in both hypoxic and redox signaling pathways in cancer biology. Endogenously produced by enzymes such as CBS, CSE, and 3-MST, H₂S can promote or inhibit tumorigenesis depending on the context. In lung cancer, H₂S has been shown to modulate hypoxia-inducible factor activity, support mitochondrial bioenergetics under low oxygen tension, and influence ROS dynamics, thereby maintaining redox balance that favors tumor cell survival. The complex crosstalk between H₂S, hypoxia, and oxidative stress creates a permissive environment for tumor growth and immune evasion, but also offers potential vulnerabilities that can be therapeutically exploited. Targeting H₂S signaling has emerged as a promising avenue in lung cancer management. Both inhibition and controlled supplementation of H₂S are under investigation as strategies to disrupt tumor adaptation to hypoxia and oxidative stress. This review highlights the dualistic nature of H₂S in lung cancer progression, explores its mechanisms of action in the context of hypoxic and oxidative stress pathways, and discusses the diagnostic and therapeutic potential of modulating the H₂S axis for improved clinical outcomes.

Background: Perineal wound healing complications frequently occur following abdominoperineal resection (APR) for low-lying rectal cancers, posing significant reconstructive challenges. Among various reconstructive options, gracilis muscle flaps have gained prominence due to their reliability in addressing sacral dead-space defects. Despite their popularity, decision-making criteria regarding unilateral versus bilateral gracilis flap use, supplementary adipose tissue flaps, and optimal timing for reconstruction remain inadequately defined.

Materials and methods: We conducted a retrospective single-center cohort study including 25 patients who underwent perineal reconstruction using unilateral or bilateral gracilis muscle flaps after APR complications. Variables collected encompassed demographic characteristics, preoperative treatments, operative details, and postoperative outcomes classified according to the Clavien-Dindo criteria. Additionally, we assessed the efficacy of supplementary adipose tissue flaps harvested from the ischiorectal region.

Results: Among the 25 patients studied, unilateral gracilis flap reconstruction was performed in 64%, and bilateral flaps in 36%. Eleven cases (44%) received supplementary adipose tissue flaps. The overall complication rate was 44%, with 28% requiring surgical revision. Negative pressure wound therapy (NPWT) cycles pre-reconstruction significantly correlated with higher complication rates (P = 0.013), likely reflecting underlying wound severity. Although not statistically significant, a trend indicated that a shorter interval between oncological resection and reconstructive surgery resulted in fewer complications (mean: 8.2 vs. 34.8 months; P = 0.14). Ultimately, complete healing was achieved in all patients.

Conclusion: Gracilis muscle flaps, complemented by ischiorectal adipose flaps, represent an effective strategy for perineal reconstruction post-APR, though the optimal timing warrants further investigation. Although these findings are limited by the small cohort size and retrospective design, minimizing preoperative NPWT cycles and avoiding excessive delays in reconstruction may improve clinical outcomes.