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Introduction: Cirrhosis is associated with significant morbidity and frequent hospital readmissions due to recurrent complications. Thirty-day readmission is an important quality metric linked to increased healthcare costs and mortality. Identifying predictors of early readmission may help guide targeted interventions.

Methods: We conducted a retrospective cohort study of adult patients (≥18 years) with cirrhosis admitted to a tertiary care center in Bahrain between January 1, 2023, and December 31, 2025. Demographic, clinical, and laboratory data were collected from electronic medical records. The primary outcome was 30-day hospital readmission. Multivariate logistic regression was used to identify independent predictors.

Results: A total of 527 patients were included, with a mean age of 56.8 ± 13.2 years; 324 (61.5%) were male. The most common etiologies were metabolic dysfunction-associated steatotic liver disease (203 (38.5%)), alcohol-related liver disease (143 (27.1%)), and viral hepatitis (130 (24.7%)). Ascites was present in 329 patients (62.4%) and hepatic encephalopathy in 184 patients (34.9%). Hyponatremia (serum sodium < 130 mmol/L) occurred in 148 patients (28.1%), and prior hospitalization within six months occurred in 211 patients (40.0%). The mean Model for End-Stage Liver Disease (MELD) score was 16.7 ± 6.3. The 30-day readmission rate was 144 (27.3%). Independent predictors of readmission included a higher MELD score (odds ratio (OR) 1.08 per point increase, 95% confidence interval (CI) 1.04-1.12, p < 0.001), ascites (OR 2.14, 95% CI 1.38-3.31, p = 0.001), hepatic encephalopathy (OR 1.89, 95% CI 1.21-2.95, p = 0.005), hyponatremia (OR 1.76, 95% CI 1.12-2.77, p = 0.014), and prior hospitalization (OR 2.58, 95% CI 1.65-4.04, p < 0.001).

Conclusion: Thirty-day readmission among patients with cirrhosis is common and is primarily driven by disease severity and complications. Higher MELD score, ascites, hepatic encephalopathy, hyponatremia, and prior hospitalization were independently associated with increased readmission risk. Identifying high-risk patients may allow implementation of targeted interventions, including optimization of medical management and early outpatient follow-up, to reduce readmission and improve outcomes.

Bilateral zygomatic arch fractures are uncommon but may result in significant midfacial deformity and functional impairment, particularly when fractures are comminuted and structural continuity is compromised. This report describes the surgical management of a 49-year-old male who sustained severe facial trauma following a mountain-climbing accident, resulting in comminuted bilateral zygomatic arch fractures and marked midfacial disfigurement. Due to the complexity of the injury and loss of structural support, autogenous costal cartilage grafting combined with titanium mesh fixation was selected for reconstruction. Under general anesthesia, bilateral preauricular and infraorbital approaches were used to expose the fracture sites. Autogenous costal cartilage was harvested from the left costal cartilage (typically sixth-eighth rib), contoured according to the anatomical requirements of both zygomatic arches, and positioned to restore midfacial contour. Titanium mesh and screws were applied to achieve rigid fixation and maintain structural stability. Short-term follow-up of three months demonstrated satisfactory healing without complications. Facial symmetry and midfacial projection were successfully restored, and the patient reported high satisfaction with the surgical results. The patient described in this report is also one of the authors, and this dual role is disclosed for ethical transparency. This case highlights autogenous costal cartilage grafting with titanium mesh fixation as a viable reconstructive option in complex bilateral zygomatic arch fractures when conventional reduction and fixation may be insufficient.

Background Dual HER2 blockade with pertuzumab, trastuzumab, and a taxane is the current standard first-line treatment for HER2-positive metastatic breast cancer (mBC), based on pivotal trials such as the CLEOPATRA. Since 2014, this regimen has been implemented in the Costa Rican public healthcare system. However, real-world data from Central America are lacking. Methods We conducted a retrospective, multicenter observational study of 148 patients with histologically confirmed HER2-positive mBC who were treated between August 2015 and August 2021 at five Costa Rican public hospitals. Primary endpoints were progression-free survival (PFS), overall survival (OS), and safety profile. Survival analysis was performed using Kaplan-Meier estimates. Results Median age was 58 years; 95% had ECOG 0-1; 54% were hormone receptor-positive. Visceral metastases were present in 37.8%, and 4.7% had brain metastases at diagnosis. Paclitaxel was the most used taxane (85%). Median duration of anti-HER2 therapy was 22.7 months. Median PFS was 19 months (95% CI: 15-25), and median OS was 73 months (95% CI: 38-74), with a median follow-up of 27.5 months. Most adverse events were grade 1-2, with peripheral sensory neuropathy (34%) and diarrhea (21%) being the most common. Grade 3 cardiotoxicity occurred in two patients. Subgroup analysis by hormone receptor status showed no statistically significant differences in PFS (HR-positive: 18.2 months (95% CI 14.1-22.3) vs. HR-negative: 20.1 months (95% CI 15.8-24.4); p = 0.42) or OS (HR-positive: 71 months (95% CI 36-106) vs. HR-negative: 74 months (95% CI 40-108); p = 0.38). Conclusion This first Central American real-world study demonstrates that first-line pertuzumab, trastuzumab, and taxane yields PFS, OS, and safety outcomes comparable to pivotal trials in HER2-positive mBC, despite including patients with prior trastuzumab exposure and brain metastases. These findings contribute to regional real-world evidence and underscore the need for neurological monitoring, given the high rate of central nervous system (CNS) progression. Cross-study comparisons remain descriptive due to population and design differences.

Pyridostigmine is an acetylcholinesterase inhibitor widely used for the symptomatic treatment of myasthenia gravis (MG). Cholinergic crisis is a rare but life-threatening adverse effect caused by excessive cholinergic stimulation. Since pyridostigmine is primarily excreted by the kidneys, standard doses may become excessive in the presence of severe renal impairment. We report a case of cholinergic crisis in an elderly patient on maintenance hemodialysis (HD) who exhibited significant weight loss and severe hypoalbuminemia. An 81-year-old male with acetylcholine receptor antibody-positive ocular MG on maintenance HD developed acute loss of consciousness and severe hypoxemia immediately after his usual pyridostigmine therapy (60 mg twice daily). He presented with marked miosis, profuse secretions, severe bradycardia, and hypotension. Arterial blood gas analysis revealed extreme hypercapnia, and serum cholinesterase (ChE) levels were markedly depressed (17 U/L; reference range: 240-486 U/L). Pyridostigmine was immediately discontinued, and atropine was administered via bolus followed by continuous infusion. During the period of hemodynamic instability, the patient required tracheal intubation and continuous hemodiafiltration (CHDF). Continuous atropine administration was gradually tapered and discontinued on day 12. A tracheostomy was performed on day 12, the patient was successfully weaned from mechanical ventilation on day 16, and he was discharged from the intensive care unit (ICU) on day 22. This case underscores that even standard doses of pyridostigmine can induce a cholinergic crisis in patients with severe renal failure receiving HD. Furthermore, significant weight loss and severe hypoalbuminemia may have increased the patient's vulnerability to severe cholinergic toxicity.

The single anastomosis duodeno-ileal sleeve (SADI-S) presents a simplified alternative to the duodenal switch. However, this procedure may result in malabsorption and associated complications for some patients. Revisional bariatric surgery can be extremely challenging, particularly following a previous intervention, and conventional laparoscopy may be limited in these complex cases. The introduction of robotic surgery has improved both precision and safety in such cases. This report describes a scarce case of robotic conversion from SADI-S to Roux-en-Y gastric bypass, illustrating its feasibility and favorable patient outcomes.

Introduction: Appendiceal mucinous neoplasms (AMNs) are rare tumors with the potential to progress to pseudomyxoma peritonei (PMP). Identification of prognostic factors may improve surgical management and follow-up strategies.

Objective: This study aimed to analyze clinicopathological factors associated with the development of PMP in patients with AMNs treated at a tertiary care hospital in Mexico.

Methods: A retrospective study was conducted in Hospital Médica Sur, Mexico City, Mexico, including 30 patients with histologically confirmed AMNs between 2018 and 2023. Clinical, surgical, histological, and laboratory variables were analyzed. Bivariate analyses and binary logistic regression models were performed to identify factors associated with the development of PMP.

Results: Appendiceal perforation was the only factor significantly associated with the development of PMP, as the absence of perforation was linked to significantly lower odds of disease (odds ratio (OR): 0.090; 95% confidence interval (CI): 0.010-0.798; p = 0.031). Histological subtypes other than low-grade appendiceal mucinous neoplasm (LAMN) showed a nonsignificant trend toward association (p = 0.076).

Conclusion: Appendiceal perforation was the main factor associated with the development of PMP in this cohort. Its identification may help guide surgical decision-making and individualized postoperative surveillance strategies.

This review article provides a comprehensive overview of the main monomers used in transdermal drug delivery systems (TDDS), such as acrylates, methacrylates, polyethylene glycol acrylates, crosslinking monomers, and specialty monomers. It examines their impact on key quality attributes (critical quality attributes), including drug release kinetics, adhesion-cohesion balance, mechanical strength, and stability under thermal and humidity stress. The article also summarizes Food and Drug Administration and European Medicines Agency requirements for monomer characterization in regulatory submissions, details analytical techniques for measuring residual monomers and analyzing the resulting polymers, and highlights recent developments in the regulatory landscape. Monomer selection is emphasized as a vital scientific and regulatory factor that influences TDDS quality, performance, and patient safety.

[This corrects the article DOI: 10.7759/cureus.103912.].

Isolated true aneurysms of the deep femoral artery (DFAA) are exceptionally rare clinical entities. This report aims to describe the diagnostic challenges and therapeutic dilemmas associated with a huge 5.3 cm isolated DFAA in a patient with coexisting systemic hematological malignancy. A 77-year-old male patient with multiple myeloma underwent radiographic investigation for skeletal pain, which incidentally identified a 5.3 cm isolated left DFAA. Multi-planar CT angiography (CTA) characterized the lesion as a 10-cm long fusiform aneurysm featuring significant mural thrombus (3.7 cm thick) and irregular luminal ulcerations. Given the high risk of rupture, open surgical excision and ligation were recommended. However, following comprehensive clinical counseling regarding the natural history of the disease, the patient opted for conservative management with watchful waiting. Isolated DFAAs of this magnitude are rare and may be clinically masked by systemic pathologies such as multiple myeloma. This case highlights the diagnostic utility of CTA in characterizing complex vascular lesions and illustrates the ethical challenges that arise when patients decline indicated surgical treatment.

Background: Central venous access is essential in perioperative management of major abdominal surgery. While centrally inserted central venous catheters (CVCs) are widely used, insertion-related mechanical complications remain a concern. Peripherally inserted central catheters (PICCs) may represent an alternative strategy, particularly when integrated into nurse-led task-sharing workflows. This study evaluated the feasibility and procedural outcomes of ultrasound-guided PICC placement during general anesthesia.

Methods: This single-center retrospective observational study included 86 adult patients undergoing gastrointestinal surgery under general anesthesia who required central venous access between January 2023 and December 2025. Patients were divided into a PICC group (n = 41) and a CVC group (n = 45). The primary outcome was catheter placement time (minutes). Secondary outcomes included catheter dwell time (days), catheter-related bloodstream infection (CRBSI), and catheter occlusion with intraluminal thrombus. CRBSI was assessed in accordance with CDC guidance, and patients were followed until catheter removal.

Results: Baseline characteristics were comparable between groups. Catheter placement time was significantly shorter in the PICC group than in the CVC group (5.5 ± 3.1 vs. 7.0 ± 2.3 minutes, p = 0.013). Catheter dwell time was longer in the PICC group (7.1 ± 3.1 vs. 3.3 ± 1.7 days, p < 0.001). CRBSI incidence did not significantly differ between groups (2.4% vs. 8.9%, p = 0.363). Catheter occlusion with intraluminal thrombus occurred in one patient (2.4%) in the PICC group and in none in the CVC group. All catheter placements were successful (100% in both groups).

Conclusions: Ultrasound-guided PICC placement during general anesthesia was associated with shorter catheter placement time and longer catheter duration than CVC placement in this retrospective cohort. Catheter-related complications were infrequent; however, definitive conclusions regarding comparative safety are limited by the observational design and low event counts. These findings support the feasibility of perioperative PICC use and suggest potential workflow implications within structured nurse-led task-sharing models. Further prospective multicenter studies incorporating direct operating room workflow metrics and catheter-day-based outcomes are warranted.