Cureus最新文献

Background Laparoscopic bile duct exploration (LBDE) enables single-stage management of common bile duct (CBD) stones. However, large or impacted stones often necessitate choledochotomy, which is associated with increased morbidity and longer operative duration. In 2025, routine intraoperative lithotripsy was introduced in our unit to facilitate trans-cystic stone clearance. Aim To evaluate the impact of routine intraoperative lithotripsy on operative approach and perioperative outcomes by comparing cases performed in 2025 with those performed between 2020 and 2024. Methods A retrospective cohort study was conducted of all consecutive patients undergoing LBDE between January 2020 and December 2025 at a single upper gastrointestinal surgical unit. Patients were divided into two groups: pre-lithotripsy era (2020-2024) and lithotripsy era (2025). The primary outcome was the rate of choledochotomy. Secondary outcomes included operative time, bile leak, endoscopic retrograde cholangiopancreatography (ERCP) reintervention, and length of stay. Categorical variables were compared using chi-square testing and continuous variables using Mann-Whitney U testing. Results A total of 301 patients were included (2020-2024: n=225; 2025: n=76). The choledochotomy rate decreased significantly following the introduction of lithotripsy (34.2% (n=77) vs 5.2% (n=4), p<0.001). Median operative time reduced from 159 minutes to 120 minutes (p=0.005). No bile leaks occurred in 2025 compared with 2.7% (n=6) in the earlier cohort (p=0.335). There were no significant differences in ERCP reintervention (7.6% (n=17) vs 5.3% (n=5.3), p=0.75) or length of stay (median 2 vs 3 days, p=0.14). Conclusion Routine intraoperative lithotripsy significantly reduced the need for choledochotomy and shortened operative duration. Its introduction has transformed surgical strategy toward near-universal trans-cystic completion with fewer post-operative complications.

Diseases know no borders; neither should the solutions.  - Sir George Alleyne, Address to the Pan American Health Organization, 1998 China's rapid expansion in pharmaceutical innovation has prompted analyses that variously portray this rise as a geographic shift, a regulatory challenge, or a geopolitical threat. Drawing on recent contributions from Kinch et al., Vokinger et al., Gautam, and Gottlieb, this commentary examines how broader discussions of China's rise often conflate geography with geopolitics, obscuring the more consequential structural transformation underway in global drug discovery, development, and regulation. China's ascent reflects regulatory reform, AI‑enabled discovery, and the out‑licensing of high‑value clinical assets that increasingly shape multinational R&D pipelines. Although geopolitical tensions around data integrity and market access are real, they should not eclipse opportunities for regulatory cooperation, shared standards, and improved patient access. Meanwhile, US vulnerabilities arise less from China's progress than from domestic policy decisions that weaken scientific capacity and global health partnerships. A structural, evidence‑based framing, rather than one rooted in rivalry, offers a more constructive foundation for policy, emphasizing regulatory quality and sustained investment in US biomedical infrastructure. The organizing principle for global drug innovation should be health, not geopolitical competition.

Benzodiazepine intoxication in children commonly manifests with central nervous system depression, hypotonia, and ataxia. Ocular motor abnormalities are uncommon and may mimic serious neurological disorders, frequently prompting urgent neuroimaging. We report the case of an eight-year-old boy who presented with sudden-onset convergent strabismus approximately 30 minutes after accidental ingestion of 10 mg of lorazepam. On admission, he was hemodynamically stable with a Glasgow Coma Scale score of 15/15. Neurological examination was unremarkable except for acute esotropia. Brain computed tomography revealed no abnormalities, and urine toxicology screening was positive for benzodiazepines. The patient was managed conservatively with close clinical observation without administration of flumazenil. Complete spontaneous resolution of the ocular deviation occurred within 12 hours. This case highlights that isolated acute strabismus may represent a rare but reversible manifestation of benzodiazepine intoxication in children. Awareness of this presentation may help clinicians consider toxicological causes in the differential diagnosis and avoid unnecessary invasive investigations.

Objective:  This study aims to evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) in post-chemoradiation restaging of rectal carcinoma. The primary endpoints were T (tumor) and N (nodal) staging accuracy using surgical histopathology as the reference standard. Diagnostic accuracy was defined in terms of sensitivity, specificity, positive predictive value, negative predictive value, and overall concordance. A secondary objective was to assess the role of MDCT in detecting distant metastasis in correlation with intraoperative and available clinical findings.

Methodology: A prospective analytical observational study was conducted in the Department of Radiodiagnosis at M. S. Ramaiah Hospitals, Bengaluru, from November 2018 to June 2020. Twenty-seven patients with biopsy-proven rectal carcinoma underwent CT imaging of the abdomen and pelvis following chemoradiation and before surgical resection. MDCT-based T (tumor), N (nodal), and M (metastasis) staging were compared with intraoperative assessments and histopathological results. Diagnostic performance was evaluated by calculating sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy.

Results: A total of 27 patients were analyzed, including 16 (59.3%) females and 11 (40.7%) males, with most aged 51-70 years. Bleeding per rectum was the most common symptom in 26 (96.3%) patients, followed by blood in stools in 24 (88.9%) and anemia in 21 (77.8%). Tumors were primarily located in the rectum among 21 (77.8%) patients, and were predominantly adenocarcinomas in 21 (77.8%) patients. Perirectal fat involvement was observed in 18 (66.7%) patients, and regional lymph node invasion in eight (29.6%).

Conclusion: MDCT is a reliable modality for staging rectal cancer, particularly for advanced stages (T3-T4), demonstrating high accuracy in assessing tumor extent, nodal involvement, and distant metastases. Its sensitivity for early-stage lesions remains lower than that of MRI, highlighting the complementary role of multimodal imaging in preoperative evaluation.

[This corrects the article DOI: 10.7759/cureus.41811.].

Fixed orthodontic treatment is commonly associated with pain and discomfort, particularly during the initial stages, which may influence patient adherence and satisfaction; however, a comprehensive synthesis of evidence, specifically focused on the adult population, remains limited. This systematic review aimed to evaluate pain and oral health-related quality of life (OHRQoL) in adult patients undergoing fixed orthodontic treatment. Electronic searches were conducted up to August 2025 across multiple databases, including PubMed®, Web of Science™, Scopus®, Google™ Scholar, PsycINFO®, EMBASE®, and the Cochrane Library, with no restrictions on publication date or language. Observational studies, randomized controlled trials (RCTs), and controlled clinical trials (CCTs) involving patients aged 18 years or older, treated with conventional fixed appliances, were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the RoB-2 and ROBINS-I tools. Meta-analysis was performed using RevMan 5.4 (The Cochrane Collaboration, The Nordic Cochrane Center, Copenhagen, Denmark), and the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. A total of 14 studies involving 1,022 adult patients were included, comprising seven RCTs, three CCTs, three cohort studies, and one cross-sectional study. The mean age of participants ranged from 18.87 to 38 years, with a female predominance of approximately 61%. Pain intensity peaked at 24 hours post-activation, with Visual Analog Scale scores ranging widely from 19.5 to 56.7. Meta-analysis of two studies revealed a statistically and clinically significant reduction in pain from day 1 to week 1 (mean difference = 20.83, 95% confidence interval: 11.70 to 29.97, p < 0.00001, I² = 67%), with pain continuing to decline over subsequent weeks. OHRQoL, primarily measured using the Oral Health Impact Profile-14, showed initial impairment, followed by significant improvement over time. However, the overall certainty of evidence for both outcomes was rated as very low to low. In conclusion, fixed orthodontic treatment in adult patients is consistently associated with moderate-to-high pain levels that peak around 24 hours and decrease significantly within the first week, while OHRQoL follows a parallel pattern of initial decline, followed by measurable improvement within the first month. Clinicians may use these findings to counsel adult patients and set realistic expectations regarding the transient nature of initial discomfort. Given the very low to low certainty of evidence, there is an urgent need for more well-designed longitudinal studies, with standardized outcome assessment time points and reporting metrics, to strengthen the evidence base.

Background and objective:  In patients with nonvalvular atrial fibrillation (NVAF) undergoing combined catheter ablation (CA) and left atrial appendage occlusion (LAAO), bleeding events may occur even among those classified as low risk by the HAS-BLED score (≤2). This exploratory study aimed to identify factors associated with post-procedural bleeding in this specific population.

Methods:  This single-center retrospective analysis included 209 NVAF patients with HAS-BLED ≤2 who underwent first-time CA and LAAO between 2021 and 2023. Patients with active bleeding or severe hepatic/renal impairment (estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m²) were excluded. The primary outcome was any Bleeding Academic Research Consortium (BARC)-defined bleeding event over a mean follow-up of 30 months. Bleeding severity (BARC 1, ≥2, ≥3) and timing (periprocedural (≤30 days) vs. late) were characterized. Given the limited number of bleeding events (n=10), multivariable analysis employed Firth's penalized-likelihood regression to reduce small-sample bias. Model performance was assessed using the c-statistic with optimism-corrected bootstrap validation.

Results:  Ten patients (4.78%) experienced bleeding events (incidence rate: 1.96 per 100 person-years). Bleeding was predominantly BARC ≥2 (n=8, 80%), with five events (50%) occurring periprocedurally. In univariable analysis, age (OR 1.17 per year, 95% CI 1.05-1.30), CHA₂DS₂-VASc score (OR 2.04, 95% CI 1.28-3.26), and renal insufficiency (eGFR <60 mL/min/1.73 m²; OR 23.87, 95% CI 5.73-99.49) were associated with bleeding. In multivariable Firth regression, age (adjusted OR (aOR) 1.13 per year, 95% CI 1.03-1.28; absolute risk difference per 10-year increase: +5.2%), history of myocardial infarction (MI) (aOR 36.82, 95% CI 2.62-446.55; absolute risk difference: +41.3%), and renal insufficiency (aOR 21.16, 95% CI 4.50-106.48; absolute risk difference: +35.8%) remained independently associated with bleeding. The optimism-corrected c-statistic was 0.82 (95% CI 0.71-0.91). However, with only 10 events and three predictors examined, the analysis is susceptible to overfitting, and effect estimates, particularly for MI, have limited precision.

Conclusion:  In this exploratory, hypothesis-generating analysis of NVAF patients with low HAS-BLED scores undergoing combined CA and LAAO, renal insufficiency, history of MI, and advanced age were associated with bleeding events. These findings suggest that conventional risk scores may not fully capture bleeding risk in this setting but require validation in larger, prospective multicenter cohorts before clinical application.

Background and objectives: In Greece, both the preterm birth rate (PBR) and the low birthweight rate (LBWR) have risen sharply in recent decades, reaching among the highest levels in high-income countries and posing a substantial public health concern. This study aimed to quantify the contribution of preterm births to the national LBW burden and to determine the extent to which the rise in PBR has driven the increase in LBWR.

Methods: The analysis included 4,585,090 live births recorded in Greece from 1980 to 2023, stratified by gestational age and birthweight. Temporal trends were assessed using joinpoint regression analysis. For each segment between two joinpoints, the annual percent change (APC) was calculated with 95% confidence intervals (CIs), and statistical significance was set at p < 0.05.

Results: From 1980 to 2023, both LBWR and PBR increased substantially and were strongly correlated (rho = 0.858, 95% CI: 0.725-0.929, p < 0.001). The preterm LBWR remained stable from 1987 to 2004, then rose significantly thereafter (APC = 0.5, 95% CI: 0.2-0.9, p = 0.027). In contrast, the term LBWR increased during the 1980s and 1990s, declined significantly from 2002 to 2017 (APC = -3.5, 95% CI: -6.2 to -2.7, p = 0.033), and then stabilized. The population attributable risk (PAR, %) of LBW due to prematurity increased from a low of 25.8% in 1991 to a historic peak of 68.2% in 2021 (67.1% in 2023), with statistically significant rises during 1991-2004 (APC = 2.5, 95% CI: 1.3-7.7, p = 0.024), 2004-2009 (APC = 9.1, 95% CI: 2.4-13.9, p = 0.021), and 2009-2023 (APC = 1.4, 95% CI: 0.7-2.0, p = 0.014). The proportion of LBW neonates born preterm rose from a minimum of 27.8% in 1991 to a peak of 72.0% in 2021 (71.2% in 2023). The entire increase in LBWR between 1991 and 2023 was fully explained by the concurrent rise in PBR.

Conclusions: This nationwide study demonstrates that preterm birth is the principal driver of Greece's high LBWR. The population risk of LBW attributable to prematurity has increased markedly over the past three decades, and the sustained rise in LBWR is entirely accounted for by the parallel increase in PBR. These findings underscore the urgent need for targeted, evidence-based clinical and public health strategies to reduce prematurity and improve perinatal outcomes.

Angiosarcoma is a rare and aggressive malignancy of vascular endothelial origin, characterized by rapid progression and early metastatic dissemination. GI involvement is uncommon, and colonic metastasis from a cutaneous primary is exceptionally rare. We report the case of an 85-year-old man with a history of cutaneous angiosarcoma of the right cheek who presented with recurrent rectal bleeding and transfusion-dependent anemia. Colonoscopy demonstrated a large, ulcerated lesion in the sigmoid colon, causing luminal narrowing and active hemorrhage. Preoperative fluorodeoxyglucose PET-CT demonstrated focal thickening of the sigmoid colon with mild metabolic uptake, as well as increased uptake within the left pleura, raising suspicion for metastatic disease. Histopathological examination of the sigmoid lesion confirmed metastatic angiosarcoma. In the setting of ongoing bleeding and hemodynamic compromise, the patient underwent an urgent Hartmann's procedure, which achieved definitive hemorrhage control. The postoperative course was uncomplicated, with significant clinical improvement. Despite the typically aggressive behavior associated with angiosarcoma, the patient remains clinically well nearly two years following resection. This case highlights the rare occurrence of colonic metastasis from cutaneous angiosarcoma presenting as life-threatening lower GI bleeding and underscores the role of surgical resection in achieving effective hemorrhage control and meaningful clinical outcomes in selected patients.

Esophageal perforation (Boerhaave syndrome) is a rare but life-threatening condition that may mimic other causes of upper gastrointestinal bleeding, making early diagnosis challenging. We report a 76-year-old woman with disseminated breast cancer who presented with massive hematemesis and profound hemodynamic instability, initially suspected to represent variceal bleeding. Emergency endoscopy achieved hemostasis at the gastroesophageal junction but did not identify a perforation. During anesthesia, point-of-care ultrasound revealed a large right-sided pleural effusion, prompting CT imaging. CT demonstrated a massive right-sided hydropneumothorax, complete lung collapse, and mediastinal air consistent with esophageal perforation. Despite stabilization and broad-spectrum antibiotics, the patient developed sepsis. Given her advanced malignancy, frailty, and poor prognosis, invasive interventions were withheld and care was transitioned to a palliative approach. This case highlights the diagnostic difficulty of distinguishing Boerhaave syndrome from other causes of massive hematemesis and underscores the value of CT imaging when endoscopy is inconclusive.