Ajith Kumar Sankarankutty

Rationale: Limited evidence exists on the long‐term impact of Clinical Decision Support Systems (CDSS) on potassium safety in middle‐income countries, with most studies focusing on short‐term outcomes in resource‐rich settings. Aims and Objectives: This study evaluates the long‐term effectiveness of a CDSS in reducing potassium‐related adverse events in a Brazilian tertiary‐care hospital from 2006 to 2023. Methods: This retrospective observational study analysed all potassium‐containing prescriptions (oral and intravenous) at a Brazilian tertiary‐care teaching hospital. The study compared the pre‐implementation (2006–2014) and post‐implementation (2014–2023) phases of a CDSS that monitors and blocks prescriptions exceeding predefined safety limits for potassium concentration, infusion rate, and daily dose. Near misses were retrospectively identified by applying the same CDSS‐defined rules to completed prescriptions—both before and after CDSS implementation. Trends in adverse events and blocked prescription attempts were analysed using Prais‐Winsten regression. Data were obtained directly from hospital databases, without coding or transformation. The study adhered to the RECORD statement and received ethical approval. Results: Of 9,308 drug‐related adverse events recorded between 2013 and 2023, 64 (0.7%) involved potassium salts. Despite an increase in overall drug‐related events ( p < 0.001), the proportion involving potassium decreased from 2.8% in 2013% to 0.2% in 2023 ( p = 0.008). After CDSS implementation, 90,741 potassium prescriptions were submitted, of which 38,961 (42.9%) triggered CDSS blocked attempts, showing a consistent upward trend ( β = 20.4, p < 0.001). Most blocked attempts were due to violations of intravenous concentration (60%) and infusion rate (18%) limits. Near‐miss prescriptions remained proportionally high [median 27.4% (IQR: 17.5–32.2)] throughout the post‐CDSS phase. Conclusion: This study demonstrates the long‐term effectiveness of a potassium‐specific CDSS in reducing adverse drug events in a middle‐income setting. However, persistent increases in blocked attempts and near misses suggest potential issues related to alert fatigue, overreliance on CDSS, and override practices, highlighting the need for ongoing system refinement and staff training.

Background: Single-stage outpatient treatment of cholecystocholedocholithiasis is feasible, highlighting the importance of appropriate patient selection, professional training, and healthcare service organization to support this approach. Aim: To identify clinical and procedural factors associated with outpatient management and hospital stay following single-stage laparoendoscopic treatment of cholecystocholedocholithiasis. Methods: A retrospective cohort study was conducted at hospitals affiliated with the Ribeirão Preto School of Medicine, Universidade de São Paulo (FMRP-USP), between 2019 and 2024. Patients were stratified into three groups according to care setting: outpatient (G1); outpatient with overnight stay (G2); and inpatient (G3). Clinical, surgical, and outcome data were analyzed using logistic regression models, χ2 tests, and Fisher’s exact tests (p=0.05). Results: Among 177 patients included, 41 were allocated to G1, 80 to G2, and 56 to G3. Compared with G2, G1 patients had shorter operative time (124.2 vs. 143.8 min; p=0.038), more frequent use of the Rendez-Vous technique (p=0.044), and less frequent use of papillary dilation (p=0.041). Patients in G3 had a higher prevalence of ASA III physical status (p=0.045), higher rates of postoperative complications (p=0.025) and biliary stent use (p=0.001), and lower bile duct clearance rates (p=0.004). Conclusions: Single-stage outpatient laparoendoscopic treatment of cholecystocholedocholithiasis is safe and effective. Clinical severity, treatment complexity, and failure of bile duct clearance were more strongly associated with inpatient hospitalization, whereas overnight stay among outpatients was not associated with improved postoperative outcomes. The implementation of enhanced recovery protocols and telemedicine-based postoperative assessment strategies may further reduce hospital stay.

Objective: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease, affects approximately 38% of the global population. MASLD’s strong association with obesity and type 2 diabetes positions it as an increasingly prevalent indication for liver transplantation. Hence, this study sought to assess the prevalence of MASLD as an indication for liver transplantation, to characterize the clinical and epidemiological profile of the affected population, and to investigate the rates of post-transplant recurrence and de novo occurrence. [...] Abstract Objective: Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease, affects approximately 38% of the global population. MASLD’s strong association with obesity and type 2 diabetes positions it as an increasingly prevalent indication for liver transplantation. Hence, this study sought to assess the prevalence of MASLD as an indication for liver transplantation, to characterize the clinical and epidemiological profile of the affected population, and to investigate the rates of post-transplant recurrence and de novo occurrence.

The benefits of using a fibrin sealant to reinforce the pancreaticojejunal anastomosis are still contentious, a fact that justifies the study of its effects on clinical outcomes and costs of pancreaticoduodenectomy. Study of 62 consecutive patients submitted to pancreaticoduodenectomy, divided into two groups of 31 patients each: GWS = group with sealant and GWOS = group without sealant that were compared according to demographic, clinical, laboratory aspects, the incidence of postoperative pancreatic fistula (POPF), according to the definition of the International Study Group on Pancreatic Fistula, updated in 2016, and its postoperative complications categorized according to the Clavien classification, as well as hospital costs evaluated by the absorption costing method (with the exception of those related to medications). The groups were homogeneous and there were no significant differences in the postoperative clinical course or in the indicators of hospital care between them. Hard texture of pancreatic tissue was the only protective factor against the development of POPF (RR = 0.29 (95%CI:0,12–0,68); p = 0.005). Moreover, hospital costs were higher in GWS than in GWOS (p < 0.0001). The use of fibrin sealant to reinforce pancreaticojejunal anastomosis did not improve the clinical and healthcare outcomes and, in addition, increased hospital costs.

Background: It is important to obtain representative histological samples of solid biliopancreatic lesions without a clear indication for resection. The role of new needles in such task is yet to be determined. Aim: To compare performance assessment between 20G double fine needle biopsy (FNB) and conventional 22G fine needle aspiration (FNA) needles for endoscopic ultrasound (EUS)-guided biopsy. Methods: This prospective study examined 20 patients who underwent the random puncture of solid pancreatic lesions with both needles and the analysis of tissue samples by a single pathologist. Results: The ProCore 20G FNB needle provided more adequate tissue samples (16 vs. 9, p=0.039) with better cellularity quantitative scores (11 vs. 5, p=0.002) and larger diameter of the histological sample (1.51±1.3 mm vs. 0.94±0.55 mm, p=0.032) than the 22G needle. The technical success, puncture difficulty, and sample bleeding were similar between groups. The sensitivity, specificity, and diagnostic accuracy were 88.9%, 100%, and 90% and 77.8%, 100%, and 78.9% for the 20G and 22G needles, respectively. Conclusions: The samples obtained with the ProCore 20G FNB showed better histological parameters; although there was no difference in the diagnostic performance between the two needles, these findings may improve pathologist performance.

Gastric cancer is one of the main cancer-related causes of death worldwide. The curative treatment of gastric cancer consists of tumor resection and lymphadenectomy. However, surgical treatment alone is associated with high recurrence rates. Adjuvant treatment strategies have been studied over the last decades, but there have been controversial results from the initial studies. The pivotal INT0116 study demonstrated that the use of adjuvant chemoradiotherapy with 5-fluorouracil increases relapse-free and overall survival, and it has been adopted across the Western world. The high toxicity of radiochemotherapy and suboptimal surgical treatment employed, with fewer than 10% of the patients submitted to D2 lymphadenectomy, were the main study limitations. Since its publication, other adjuvant treatment modalities have been studied, and radiochemotherapy is being refined to improve its efficacy and safety. A multimodal approach has been demonstrated to significantly increase relapse-free and overall survival, and it can be offered in the form of perioperative chemotherapy, adjuvant chemoradiotherapy or adjuvant chemotherapy, regardless of the extent of lymphadenectomy. The objective of the present review is to report the major advances obtained in the last decades in the adjuvant treatment of gastric cancer as well as the perspectives of treatment based on recent knowledge of the molecular biology of the disease.