Perioperative stroke is a severe complication of cardiac surgery. We assessed the incidence of stroke over time, the association between stroke and mortality and identified preoperative factors independently associated with perioperative stroke, in a large nationwide cardiac surgery population.All patients who underwent coronary artery bypass grafting in Sweden 2006–2017 were included in a registry-based observational cohort study based on prospectively collected data. Multivariable logistic and Cox regression models were used to assess associations between perioperative stroke and mortality and to identify factors associated with stroke. The median follow-up was 6 years (range 0–12).P = 0.035]. Stroke patients had a higher overall mortality risk during follow-up , with the highest risk during the first 30 postoperative days . The strongest independent preoperative factors associated with stroke were prior cardiac surgery [adjusted OR 2.89 (1.40–5.96)], critical preoperative condition [adjusted OR 2.55 (1.73–3.76)], previous stroke [adjusted OR 1.77 (1.35–2.33)], preoperative angina requiring intravenous nitrates [adjusted OR 1.67 (1.28–2.17)], peripheral vascular disease [OR 1.63 (1.25–2.13)] and advanced age [OR 1.05 (1.03–1.06) per year].There were 441 perioperative strokes in 36 898 patients. The mean incidence was 1.2% and decreased marginally over time [adjusted odds ratio (OR) 0.97 per year , The incidence of perioperative stroke after coronary artery bypass grafting has remained stable. Patients with perioperative stroke had a markedly higher adjusted risk of death early after surgery. The risk declined over time but remained higher during the entire follow-up period. Perioperative stroke is one of the most devastating complications in cardiac surgery. Perioperative stroke is one of the most devastating complications in cardiac surgery. The incidence of perioperative stroke varies in different studies depending on the study population and stroke definition. In large registry-based studies, the incidence of perioperative stroke varies in mixed cardiac surgery populations from 1.6% to 4.6% and in coronary artery bypass grafting (CABG) patients from 1.1% to 5.7% . A recenWhile several studies have reported on the strong association between perioperative stroke and early mortality after cardiac surgery , 9, therThe study was approved by the Regional Ethics Committee in Gothenburg, Sweden (registration number 139-16 approved 4 April 2016). The Ethics Committee waived individual patient consent due to the registry-based study design. The study was performed in accordance with the 1975 Declaration of Helsinki. Before the analysis, all personal identifiers were replaced by codes to ensure anonymity.The data underlying this article were provided by the Swedish Web System for Enhancement and Development of Evidence-Based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) and national healthcare registries in Sweden. Data will be shared on request to the corresponding author with permission of SWEDEHEART and The National Board of Health and Welfare.In this nationwide, population-based cohort study, the study population was identified in the Swedish Heart Surgery Registry, which is a part of the SWEDEHEART registry . All patData from 3 national registers were merged through the personal social security number, unique for all Swedish citizens. The SWEDEHEART registry has a national coverage of 99%  and contDiagnosis for the patients’ medical history, other than in the SWEDEHEART registry, was retrieved from The National Patient Register. Registration of principal and contributory diagnoses for all hospitalizations in Sweden is mandatory. The registry has complete national coverage for all hospitalized patients since 1987 with a validity of 85–95% . The IntP-value multiplied by 2) was used for dichotomous variables.Descriptive continuous variables are presented by mean and standard deviation and categorical variables by frequencies and percentages. For comparison between 2 groups, Fisher’s exact test  with 95% confidence interval (CI) are presented from the logistic regression models. Interaction between sex and following variables was studied posthoc: age (<70 and ≥70 years), previous stroke, preoperative critical state and previous heart surgery.Univariable and multivariable logistic regression models were used to study the annual trends of the incidence of perioperative stroke and to identify factors associated with perioperative stroke. The full adjustment of the annual trends included age, sex, previous ischaemic stroke, previous transient ischaemic attack, previous haemorrhagic stroke, previous myocardial infarction, diabetes, heart failure, hypertension, atrial fibrillation, renal failure, peripheral vascular disease, history of cancer, chronic respiratory disease, acute coronary syndrome, previous heart surgery and angina at rest. Factors with a The change in incidence of perioperative stroke over calendar time was assumed to be linear and tested using logistic regression. Hosmer–Lemeshow test was performed to test goodness-of-fit.Cox regression models were used to compare mortality, between patients diagnosed with perioperative stroke and those with no perioperative stroke, within 30 days and beyond 30 days, which was divided into 3 time periods, 30 days to 1 year, 1 year to 5 years and >5 years. An overall estimate of HR for the whole time period was presented for completeness and should be interpreted as a mean HR over the studied time. The proportional hazards assumption was investigated by studying the interaction between the status of the perioperative stroke and log(follow-up time), which was found not to be satisfied for the periods 0–30 days and 30 days to 1 year. Further time splitting was therefore performed as follows: 0–7 days, 7 days to 30 days, 30 days to 3 months and 3 months to 1 year. Hazard ratio (HR) with 95% CI were presented from the Cox regression models. Survival probability was presented using the Kaplan–Meier technique.P-value <0.05 was considered significant. All analyses were performed by using SAS Software version 9.4 .All tests were two-sided and a n = 48, 0.1%) and patients with missing information about perioperative stroke , a total of 36 898 patients were included in the study. Out of these, 173 patients (0.47%) emigrated during follow-up and were censored at the time of emigration. Perioperative stroke occurred in 441 patients (1.2%). The stroke population was older, more likely to be female, and had a higher burden of comorbidities, including e.g. diabetes, previous stroke and peripheral artery disease, than the non-stroke group. The posthoc analyses revealed a significant interaction between sex and age category (P = 0.049) with larger difference in relative odds for female versus male in <70-year-old patients [OR 2.05 (95% CI 1.40–3.00)] than in ≥70-year-old patients [OR 1.30 (95% CI 1.01–1.66)]. No significant interaction was observed for previous stroke, preoperative critical state and previous heart surgery. Stroke patients had also higher logistic European System for Cardiac Operative Risk Evaluation I and CHA2DS2-VASC score. Patient characteristics in the stroke and no-stroke groups are presented in A total of 37 173 patients underwent isolated CABG in Sweden during the study period. After exclusion of patients who died during the operation day (P = 0.17 and 0.98 (95% CI 0.96–1.01), P = 0.19, respectively]. In the multi-adjusted model, there was a statistically significant but marginal reduction in the incidence of perioperative stroke over time  (Hosmer–Lemeshow goodness-of-fit test P = 0.17).The mean annual incidence of perioperative stroke was 1.2%. The annual incidence varied during the study period between 0.6% and 1.7% . In the Preoperative factors independently associated with stroke are presented with ORs in P < 0.001), P < 0.001. For the period from 30 days to 1 year, the unadjusted mortality was 12.6% (40/329) vs 1.8% (639/35 401) and the adjusted HR (aHR) 3.67 (95% CI 2.61–5.15) (P < 0.001), P-values for interaction with time were 0.0024 and <0.0001, respectively. To study change in HR over time, analyses were performed for the following time periods: first 7 days, aHR 4.40 (95% CI 2.70–7.17), 7–30 days, aHR 9.96 (95% CI 7.22–13.74), 30 days to 3 months, aHR 6.91 (95% CI 4.43–10.78) and 3 months to 1 year, aHR 2.01 (95% CI 1.15–3.49).Unadjusted mortality during the first postoperative 30 days was 16.3% (72/441) in the stroke group and 1.3% (455/36 457) in the no-stroke group  of the stroke patients and 6990/36 457 (19.5%) of the no-stroke patients died. The cumulative mortality in stroke and no-stroke patients is depicted in P < 0.001), P = 0.57). For the period after 5 years, the unadjusted mortality was 34.1% (74/224) vs 11.4% (3 366/29 505) and the aHR 1.76 (95% CI 1.39–2.23) (P < 0.001), For the period 1–5 years postoperatively, the unadjusted mortality was 13.1% (38/291) in the stroke group and 7.7% (2 530/32 871) in the no-stroke group . This is a very marginal reduction given the 1.2% absolute annual incidence and hence not clinically meaningful.In the present study, we also identified preoperative risk factors associated with perioperative stroke. The majority of these have been previously identified and were thus confirmed in the present large cohort study. It can be noted that the importance of the patient’s preoperative condition was strong, as also age, previous stroke and the presence of peripheral arterial disease. Female sex was also identified as a strong independent factor, which is in accordance with previous studies , 15. Theet al.’s [Thirty-day mortality was 13-fold higher (16.3% vs 1.3%) in patients with perioperative stroke. This confirms the extremely high mortality in perioperative stroke previously reported , 15–17. et al.’s . The incThis study has both strengths and limitations. The main limitation of this study is the retrospective nature of the study. While the data are collected prospectively, eliminating recall bias, there is always the risk of selection bias, as well as residual confounding. Another limitation of the study is the inability of our dataset to further define the severity of the stroke and its impact on the patients. Information about the proportion of stroke patients who underwent imaging is lacking in the registries. It should also be noted that we did not investigate the association between intraoperative factors and perioperative stroke. Factors such as cardiopulmonary bypass time and type of surgery have previously been shown to be associated with the risk for perioperative stroke in cardiac surgery patients , 4, 16. The strengths include the large study population in a real-world setting, the long and extensive follow-up, the nationwide coverage with a high degree of data completeness in validated mandatory national registries and databases and a primary end point  not subject to bias.There was a marginal decrease in the incidence of perioperative stroke over the study period. Patients with perioperative stroke have a markedly higher adjusted mortality risk of death early after surgery. The risk declines over time but remains higher during the entire follow-up period. Efforts to reduce the incidence of perioperative stroke are essential.EJCTS online.This work was supported by grants from the Swedish Heart-Lung Foundation (20180560 to Anders Jeppsson and 201604 to Susanne J. Nielsen), the Swedish state under the agreement between the Swedish government and the county councils concerning economic support of research and education of doctors (ALF agreement) (ALFGBG-725131 to Anders Jeppsson), Västra Götaland Region (VGFOUREG-847811 and VGFOUREG-665591 to Anders Jeppsson) and Family Nils Winberg’s Foundation. The supporting bodies had no influence on the analysis and interpretation of data, on the writing of the report or on the decision to submit the paper for publication.Conflict of interest: Anders Jeppsson has received fees for consultancy or lectures from Werfen, Boehringer-Ingelheim, Portola, Baxter and LFB, all unrelated to the present work. The remaining authors have nothing to disclose.Kristjan Jonsson: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Validation; Visualization; Writing—original draft; Writing—review & editing. Mikael Barbu: Conceptualization; Formal analysis; Writing—review & editing. Susanne J. Nielsen: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing—original draft; Writing—review & editing. Brynhildur Hafsteinsdottir: Formal analysis; Methodology; Writing—review & editing. Tomas Gudbjartsson: Conceptualization; Writing—review & editing. Elin M. Jensen: Conceptualization; Writing—review & editing. Martin Silverborn: Conceptualization; Formal analysis; Writing—review & editing. Anders Jeppsson: Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Supervision; Writing—original draft; Writing—review & editing.European Journal of Cardio-Thoracic Surgery thanks Nadejda Monsefi, Takashi Murashita and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.ezac025_Supplementary_DataClick here for additional data file.


Colorectal cancer (CRC) is the third leading cause of cancer-related death. We aimed to investigate the clinicopathological characteristics and 5-year survival in CRC. This retrospective study reviewed King Abdulaziz University Hospital records from 2009 to 2019. Tumor staging was performed using Dukes’ pathological classification. Additionally, we measured the frequency of qualitative data and performed the chi-square and Mann–Whitney U-tests. Kaplan–Meier analysis was performed to calculate overall survival. Of the 574 included patients (age (mean ± standard deviation), 55.51 ± 14.28 years), 43.2% were Saudis, and most were male (58.7%). The rectum was the most common location of CRC (30.8%); 33.1% of patients presented with abdominal pain. The dominant histological variant was mucinous adenocarcinoma (95.5%). Age at diagnosis was significantly associated with Dukes’ staging; 36.3% of individuals aged <50 years had Dukes’ D stage. The 5-year survival rate was 47.9%. Better survival was noted for those of Saudi nationality, those with Dukes’ A stage, and those who were overweight . Significantly better survival was seen in Saudi patients due to accessible healthcare and in overweight patients due to better treatment tolerance. The outcome of CRC was not related to sex or metformin use in patients with diabetes mellitus. Worldwide, colon cancer is the fourth most common cancer, and rectal cancer is the eighth most common cancer. Colorectal cancer (CRC) is the most commonly diagnosed cancer and the third leading cause of death . CRC is Saudi Arabia, among other countries, such as Japan, Kuwait, Yemen, and South Korea, has CRC as the most diagnosed cancer in the male population ,4 and thData obtained from 1990 to 2016 show that there has been a remarkable increase in the incidence of CRC in the past 26 years in the Kingdom of Saudi Arabia (KSA) . FurtherUnfortunately, the rate of death due to CRC is increasing in the KSA . A factoAlthough the mortality and incidence rates of CRC in KSA are alarmingly high ,9, to thThis study was approved by the research ethics committee of the Faculty of Medicine at KAUH under the supervision of the General Surgery Department . Informed consent was waived due to the retrospective study design.This retrospective study was conducted using hospital records from 2009 to 2019 at KAUH, a tertiary center. We screened 1064 patients with CRC; after excluding patients who did not have a histopathological report or who had a colorectal tumor as a secondary lesion, the overall sample was 574 patients.Data collected included the medical record number, date of birth, sex, nationality, age, body mass index (BMI), whether the patient was diabetic or used antidiabetic medication, presentation, whether colonoscopy was performed, tumor characteristics , and recurrence or metastasis, which were determined to be present or absent based on documented computerized tomographic findings or other documented medical reports. We also obtained information regarding surgery . In addition, we obtained data regarding patients’ chemotherapeutic agents. To study the association between age at diagnosis and other variables, we divided the patients into age groups of <50, 50–70, and >70 years. Tumor staging was implemented according to Dukes’ classification system, a pathological staging system that classifies tumors into stages A to D depending on the extent of local involvement and regional node spread.Numbers and percentages are used to express qualitative data, and the chi-square test was performed to assess the relationship between variables. Quantitative data are expressed as mean ± standard deviation, and the Mann–Whitney U-test was performed as a nonparametric test to analyze variables that were not normally distributed to evaluate the relationships between variables. The Kaplan–Meier method was used to calculate the 5-year overall survival.p-value of ≤0.05.Excel 2016 (Microsoft Corp.) was used for data entry, and statistical analysis was performed using the Statistical Package for the Social Sciences . Statistical significance was set at a The study included 574 patients with CRC, of whom 58.7% (337) were male and 41.3% (237) were female . Of the Out of all patients, 181 (31.5%) had diabetes mellitus, where the most frequent treatment used was metformin 52 (9.1%), followed by a combined regime of metformin with sulfonylurea 36 (6.2%).Histologically, 95.5% had mucinous adenocarcinoma, and more than half (67.8%) were grade 2, representing moderately differentiated tumors, followed by grade 1 (14.5%); grades 3 and 4 were found in 8.4% and 0.9% of patients, respectively. Cancer staging was performed using Dukes’ staging system; stage B was the most common stage at the time of presentation, being found in 30.1% of patients, followed by stage D (26%). Overall, 60.8% of patients had negative margins, 15.2% had lymphovascular invasion, and 13.1% had perineural invasion.The most frequent presentation of CRC was abdominal pain (33.1%) followed by rectal bleeding (29.4%). The most common diagnostic method was colonoscopy (342 patients (59.9%)). The rectum was the most frequent location of CRC (30.8%), followed by the sigmoid colon (24.7%) and rectosigmoid junction (13.2%). At the time of surgery, the mean patient age was 56.6 ± 14.47 years. More than half of the patients showed no recurrence (52.8%). Overall, 23% patients died at a mean age of 58.41 ± 14.47 years.A total of 400 patients received chemotherapy, 327 (57%) patients received capecitabine, 221 (38.5%) received XELOX, 60 (10%) received XELIRI, and 31 (5.4%) received FOLFOX.p = 0.03), as most patients aged <50 years presented at stage D (36.3%), whereas the rest of the patients presented at stage B.The relationship between Dukes’ staging and age at diagnosis was found to be significant . The percentage of death was highest in patients with Dukes’ stage D (40.3%) and grade 4 (40%), followed by those with grade 3 (35.4%). Of all the deceased patients, 34.7% had metastases. Normal-weight individuals (27.5%), followed by obese patients (25%), had a high death rate, with no significant difference (p = 0.34). There were no significant differences between death and sex. Additionally, no significant difference was found in the death rate between diabetic patients on metformin and those not on it (p = 0.78). Moreover, sex was found to have a significant relationship with Dukes’ staging (p = 0.05), as men accounted for the majority of stage C and D cases .Death was associated with multiple variables, including tumor grade, Dukes’ stage, and metastasis (p = 0.003), with a mean age of 54.1 ± 13.1 years, whereas the mean age of patients who had tumors at other locations was 56.6 ± 13.6 years.A significant relationship was found between age at diagnosis and rectal cancer . Rectal p = 0.003), with a 51.6% survival rate compared with 44.7% for those with a non-Saudi nationality. The survival rate was also higher among overweight patients , those with Dukes’ stage A , those with grade 2 cancer , those with negative margins , and those without metastasis or recurrence  and lymphovascular or perineural invasion  compared with their counterparts. However, no effect of age at diagnosis or sex was observed on patients’ survival (p > 0.05).The overall CRC survival rate at 5 years was 47.9%. Significantly better survival was noted for those of Saudi nationality , possibly due to the considerably small percent of metformin users in our sample (9%).The present study used the Kaplan–Meier method to calculate the 5-year overall survival and analyze its association with different variables. The 5-year overall survival (47.9%) was low compared to the 69% survival rate found by the King Faisal Specialist Hospital and Research Center in Jeddah, KSA, reflecting a higher quality of care . SurvivaRegarding advanced disease presentation in KSA, in 2009–2019, 36.3% of patients who presented with Dukes’ stage D were significantly younger; this is similar to the presentation during the period of 2007–2011 in which young patients presented with an advanced stage . This isIt is worth noting that the present study did not consider patients with comorbidities that might have affected their general health, such as hypercholesterolemia or inflammatory bowel diseases or medications used in such illnesses. In addition, this study was limited to a single health center, and there was insufficient documentation of all CRC data. Thus, further studies are required to verify and validate our findings with a multicenter prospective design and to identify factors that can promote improved survival in patients with CRC.Most of our patients with CRC ranged in age from 50 to 70 years, and young patients commonly presented with advanced stages of CRC. The 5-year overall survival rate was 47.9%. Saudi patients were significantly associated with better survival rates because of more accessible healthcare as well as overweight individuals due to better tolerance of cancer treatment. Additionally, this study concluded that the outcome of colorectal cancer is not related to patients’ sex or metformin use. These findings signify the need to increase public awareness, implement a national screening program, lower the threshold for suspecting CRC in younger age groups, and facilitate access to specialized medical healthcare.


The rising prevalence of prediabetes increases the population risk of type 2 diabetes mellitus (T2DM), metabolic syndrome and cardiovascular disease. Early identification by General Practitioners (GPs) provides opportunities for lifestyle modifications that can lower these risks.This study examined 16 years of hyperglycaemia-related testing for patients in Australia aged 13 years or older with, or at risk of a diagnosis of T2DM. The Bettering the Evaluation and Care of Health (BEACH) study is a national cross-sectional survey, with a single-stage, cluster sampling design. Approximately 1,000 GPs were randomly selected annually  from across Australia, who each recorded details of 100 consecutive clinical encounters with consenting patients. Point estimates were adjusted for intracluster correlation and GP characteristics.Fifteen thousand six hundred seventy nine GPs recorded details of 1,387,190 clinical encounters with patients aged 13 + years. Prediabetes and T2DM were managed at 0.25% (95% CI: 0.24–0.27%) and 3.68% (95% CI: 3.62–3.73%) of encounters respectively. By the end of the study, the proportion of encounters where prediabetes was managed was 2.3 times higher and for T2DM, 1.5 times higher. The proportion of prediabetes  and T2DM  management occasions where one or more hyperglycaemia-related tests were requested were relatively stable. However, differences in the types of tests were observed. For prediabetes, glucose tolerance tests were most common but from 2014/15, requests for HbA1c tests began to increase. For T2DM, HbA1c tests were most common, and requests for one or more glucose tests gradually declined.The observed 16-year annual trends align with the rising incidence of prediabetes and T2DM. GPs appeared to be strongly influenced by changes to the national insurance scheme and clinical guidelines for hyperglycaemia-related pathology testing. However, some GPs may have been pre-empting policy changes as there was also evidence of ‘unendorsed’ testing, notably for prediabetes, that warrants further investigation. The increasing proportion of encounters for prediabetes, coupled with a high proportion of management occasions where pathology was requested have substantial resource implications. Calls to lower the risk threshold for prediabetes screening therefore warrant an economic analysis. Ongoing, reliable, up-to-date data is needed to inform clinical practice guidelines and policy in Australia.The online version contains supplementary material available at 10.1186/s12875-022-01896-4. The prevalence of Type 2 Diabetes Mellitus (T2DM) continues to rise globally. Current estimates are that around half a billion people worldwide have T2DM and this is projected to increase by at least 50% over the next 30 years . In AustThe Royal Australian College of General Practitioners (RACGP) in collaboration with Diabetes Australia, provides patient-centered recommendations aimed at optimizing diabetes diagnosis and management . In 2016Prediabetes – a state of glucose dysregulation that does not meet the diagnostic criteria of T2DM – is considered part of the continuum of glucose dysregulation culminating in T2DM. However, it is also a recognised clinical entity and a risk condition that is independently associated with an increased risk of the metabolic syndrome and cardiovascular disease , 8. StudWhile T2DM is well defined, there is no agreed, universally recognised screening and diagnostic criteria for prediabetes –12. NotaInsulin, either fasting or with an OGTT, is another pathology test that GPs and medical specialists might use when screening and diagnosing prediabetes. Whilst these tests are not widely endorsed, since at least 2010 there have been calls to consider the role of insulin tests –15.Given the current, and potential uses of these hyperglycaemia-related tests  and their cost implications, it is important to document pathology referral activity by GPs in Australia within the broader picture of T2DM and prediabetes. A secondary analysis of publicly available Medicare Benefits Schedule (MBS) data found that between 2010 and 2019 pathology screening rates for T2DM doubled . LimitatConsequently, there remains a need to determine which hyperglycaemia-related pathology tests GPs in Australia use for managing prediabetes and T2DM, and how this may have changed over time relative to changes to Australian diabetes guidelines and MBS funding policies. The aim of this study was to investigate 16 years of GP encounters with patients aged 13 years and over (adolescents and adults) for the management of prediabetes and T2DM, and GP requests for hyperglycaemia-related pathology tests for the two conditions.Analyses of data from the Bettering the Evaluation and Care of Health (BEACH) study, a national cross-sectional survey of GP clinical activity, with single-stage, cluster sampling of GPs, conducted from April 1998 to March 2016 .The BEACH methods are described in detail elsewhere . In brieData collected in the last 16 years (April 2000 to March 2016) of the BEACH study were selected for the analysis. Only encounters with patients aged 13 years and over (adolescents and adults) were included. The ICPC-2 PLUS terms and codes rubric used to define prediabetes, T2DM, and the hyperglycaemia-related tests is outlined in Table Management occasions for prediabetes and T2DM are reported as proportions (percentage) of encounters. Over the 16 years of the study, there was a substantial increase in the number of problems managed per encounter, that in turn increased the chance of a management action occurring without any change in GP behaviour. Therefore, requests for hyperglycaemia-related tests are reported as proportions (percentage) of management occasions  was a problem being managed) rather than proportion of encounters .The types of patients seen, the problems managed, and treatments provided by the GP can be influenced by the characteristics of the GP. We accounted for the clustering of 100 encounters around each GP in the sample by using the survey means procedure in SAS v9.4 to calculate the intracluster correlation and adjust the 95% confidence intervals accordingly. Post-stratification weighting of encounter data was used to adjust for GP activity according to the number of MBS encounters each had claimed in the previous 12 months and for any minor differences in the age-sex distribution of participating GPs.Statistically significant differences between point estimates were determined by non-overlapping 95% confidence intervals, which is a more conservative approach than the traditional alpha of 0.05 .Over the 16-year study period (April 2000 to March 2016), 15,679 GPs participated in the BEACH project, recording details of 1,387,190 encounters with patients aged 13 years or older. Substantially more encounters with patients involved T2DM management than prediabetes management  and for T2DM, 27.3% (95% CI: 26.7–27.9%). For both conditions, this was relatively stable across the 16 years of the study  of management occasions in 2001/02, to a peak of 65.8% (95% CI: 58.0–73.5%) in 2008/09. This trend was attributable to OGTTs that represented the bulk of the glucose-related tests. OGTTs were requested at 24.5% (95% CI: 15.9–33.1%) of management occasions in 2001/02 and peaked at 46.3% (95% CI: 54.7%-38.0%) in 2008/09. Except for requests for HbA1c tests in 2015/16, the proportion of prediabetes management occasions where the other tests were requested were significantly lower. The lowest proportion of requests for HbA1c tests was in 2001/02 . In 2015/16, the proportion of HbA1c requests rose to 19.7% of management occasions (95% CI: 13.7–25.7%). For FBG tests, proportions ranged between 3.4% (95%CI: 1.1–5.7%) of management occasions in 2001/02 to 11.9% (95% CI: 6.1–17.7%) of management occasions in 2007/08. Requests for insulin tests were the lowest. No insulin tests were requested for prediabetes management by any of the participating GPs in four of the 16 years of the study, and the highest proportion of requests was in 2012/13   of management occasions in 2000/01, increasing to 24.8% (95% CI: 22.7–26.9%) in 2015/16. Over the same timeframe, requests for any glucose-related test fell significantly from 13.5% (95% CI: 11.4–15.6%) to 6.6% (95% CI: 5.3–7.9%) of management occasions. Requests for both FBG (95% CI ranges 1.4% to 3.7% of management occasions) and OGTT (95% CI ranges 0.1% to 1.4% of management occasions) were substantially lower than for prediabetes management, and the OGTT was the least common glucose test for T2DM management. Pathology requests for insulin were also negligible, with proportions including the upper limit of the 95% CI remaining below 0.2% of management occasions , could be recorded per encounter. Yet, it is common for GPs to order more tests, particularly when there is multimorbidity as is often the case with prediabetes and T2DM , 7. TherLimitations of this analysis included not investigating the number of tests requested for an individual patient encounter and whether there were any differences in the patient characteristics  for whom the different hyperglycaemia-related tests were requested. Another limitation was not investigating when hyperglycaemia-related tests were ordered for reasons other than T2DM and prediabetes, such as for metabolic syndrome, polycystic ovarian syndrome, other endocrine disorders, and routine health checks. Such tests for other morbidities were therefore not enumerated in this study.Annual trends in pathology requests for hyperglycaemia-related tests suggest that the clinical practice of GPs in Australia is strongly influenced by national guidelines and funding. Changes in Australian diabetes guidelines during the 16-year study corresponded with a significant increase in use of HbA1c and decline in glucose tests for the management of T2DM, and rising HbA1c testing for patients with prediabetes near the end of the study. While it is likely that glucose-related testing will remain the major mode of testing for prediabetes management, the impact of the recent 2020 joint position statement is uncertain. The BEACH study was completed in 2016, it has proved to be an essential information source for research, health system planning, and policy development. Similar projects are now urgently needed in Australia to ensure there is reliable, up-to-date, primary care data that can be used to inform government, industry, and not-for-profit organisations.Additional file 1: Supplementary Table 1. Proportion of encounters where Prediabetes and Type 2 Diabetes Mellitus (T2DM) were managed for patients aged 13+ years (2001-2 to 2015-16). Supplementary Table 2. Proportion of Prediabetes management occasions with patients aged 13+ years where General Practitioners requested hyperglycaemia-related pathology tests (2001-2 to 2015-16). Supplementary Table 3. Proportion of Type 2 Diabetes Mellitus (T2DM) management occasions with patients aged 13+ years where General Practitioners requested hyperglycaemia-related pathology tests (2001-2 to 2015-16).


There is no broad consensus concerning the management of recurrent glioblastoma (rGB). Within the French GB biobank (FGB), systemic treatment is the principal second-line treatment. None of the systemic treatment regimens was unequivocally better than the others for rGB patients. An analysis of survival outcomes based on time to first recurrence (TFR) showed that survival was best in patients with a long TFR, but that these patients constituted only a small proportion of rGB patients (13.0%). This better survival appears to be more strongly associated with response to first-line treatment than with response to second-line treatment, indicating that recurring tumors are more aggressive and/or resistant than the initial tumors in these patients. In the face of high rates of treatment failure for GB, the establishment of well-designed large cohorts of primary and rGB samples, with the help of biobanks, such as the FGB, is urgently required for the performance of solid comparative biological analyses to drive the development of new therapies for GB.p < 0.001). None of the systemic treatment regimens was unequivocally better than the others for rGB patients. An analysis of survival outcomes based on time to first recurrence (TFR) after chemoradiotherapy indicated that survival was best for patients with a long TFR  and median OS2: 13.0 months (95% CI: 11.2–17.7), but that such patients constituted only a small proportion of the total patient population (13.0%). This better survival appeared to be more strongly associated with response to first-line treatment than with response to second-line treatment, indicating that the recurring tumors were more aggressive and/or resistant than the initial tumors in these patients. In the face of high rates of treatment failure for GB, the establishment of well-designed large cohorts of primary and rGB samples, with the help of biobanks, such as the FGB, taking into account the TFR and survival outcomes of GB patients, is urgently required for solid comparative biological analyses to drive the discovery of novel prognostic and/or therapeutic clinical markers for GB.Safe maximal resection followed by radiotherapy plus concomitant and adjuvant temozolomide (TMZ) is universally accepted as the first-line treatment for glioblastoma (GB), but no standard of care has yet been defined for managing recurrent GB (rGB). We used the French GB biobank (FGB) to evaluate the second-line options currently used, with a view to defining the optimal approach and future directions in GB research. We retrospectively analyzed data for 338 patients with de novo isocitrate dehydrogenase (IDH)-wildtype GB recurring after TMZ chemoradiotherapy. Cox proportional hazards models and Kaplan–Meier analyses were used to investigate survival outcomes. Median overall survival after first surgery (OS1) was 19.8 months (95% CI: 18.5–22.0) and median OS after first progression (OS2) was 9.9 months (95% CI: 8.8–10.8). Two second-line options were noted for rGB patients in the FGB: supportive care and treatments, with systemic treatment being the treatment most frequently used. The supportive care option was independently associated with a shorter OS2 ( Glioblastoma (GB) is the most common primary intracranial malignancy, accounting for 30% of all central nervous system tumors, with an incidence of 3.22 per 100,000 individuals ,5. Tumorhttps://www.nccn.org (accessed on 1 February 2022)) and “Association des Neuro-Oncologues d’Expression Française” ). Treatment decisions often require multi-disciplinary discussions on a case-by-case basis, to determine the optimal second-line options for improving survival and health-related quality of life (HRQoL).There is universal agreement about the first-line treatment for primary GB, but the best way to manage recurrent GB (rGB) is less clear, given that none of the treatments used for recurrences has ever been shown to be more beneficial than the others ,13,14,15The aim of this retrospective study was to use French GB biobank (FGB) data to evaluate, retrospectively, the second-line options currently used, with a view to defining the optimal approach and future directions in GB research. The FGB is an academic biobank developed in 2012, following a call for tenders from the “Institut National du Cancer” (INCa) . This bi2/day, 7 days/week from the first to the last day of radiotherapy), followed by six cycles of adjuvant TMZ (150–200 mg/m2/day for 5 days during each 28-day cycle)) and (7) clinical or radiological evidence of progression after concurrent chemoradiotherapy, according to the RANO criteria [This retrospective study focused on patients included in the FGB biobank after the diagnosis of IDH-wildtype GB between January 2012 and December 2020. The following inclusion criteria were used: (1) patient aged ≥18 years, (2) newly diagnosed unilateral supratentorial GB, (3) GB with negative immunohistochemical staining for IDH1-R132H, (4) tumor resected, (5) no intraoperative chemotherapy, (6) first-line treatment according to the Stupp protocol . The protocols and regulations of the FGB network were approved by the CPP OUEST II ethics committee  and the CNIL . All adult patients from this retrospective analysis signed an informed consent form for the inclusion of their data and samples in the biobank.Baseline characteristics, such as age, sex, preoperative Karnofsky performance score (KPS), tumor laterality, tumor extent, extent of resection (EOR), O(6)-methylguanine methyltransferase (MGMT) methylation status, Stupp protocol regimen, recurrence location and follow-up, were collected from eCRFs built with Ennov Clinical software . This software is ISO9001:2015-certified for all products and activities and meets the recommendations of the FDA 21CRF Part11 and the EMA for the IT security of clinical data. The methylation status of the MGMT promoter was assessed, according to local standards, by methylation-specific PCR or pyrosequencing. EOR was recorded by the surgeon performing the operation or was determined from a postoperative MRI scan performed within 48 h of surgery by a neuroradiologist. EOR was classified as gross total resection , subtotal resection  or partial resection . EOR1 was the extent of the initial tumor resection and EOR2, the extent of the second tumor resection. The recurrence was considered local if it occurred at the same site as the initial tumor and distant if it had spread to another site. Time to first recurrence (TFR) was defined as the time between the date on which chemoradiotherapy ended and the date of first progression. TFR was classified as follows: short TFR (≤6 months), intermediate TFR (7 to 17 months) and long TFR (≥18 months). Progression-free survival (PFS1) was measured from the date of initial surgery to the date of first progression. PFS2 was defined as the time between the first and second progression. Overall survival (OS1) was calculated from the date of initial surgery to the date of last follow-up or death. OS2 was measured from the date of first progression to the date of last follow-up or death. Patients alive at last follow-up were censored.p-values were adjusted by the Benjamini–Hochberg (BH) method for multiple testing. Spearman’s rank correlation analyses were performed to evaluate the relationship between two variables. Univariate Cox regression analysis was performed with the covariates of all patients to screen for factors associated with OS1 and OS2. Variables with raw p-values < 0.25 in univariate analysis were included in multivariate Cox regression analysis, unless they were correlated with each other. The global statistical significance of the Cox model was checked in three alternative tests . The Cox model was also tested by two types of diagnostics: Schoenfeld residuals, to check the assumption of proportional hazards, and the determination of dfbeta values to investigate influential outliers. Survival curves were plotted according to the Kaplan–Meier method and were compared in log-rank tests. Statistical analyses were performed with R software ). Values of p < 0.05 were considered statistically significant.Differences between groups were assessed with Chi-squared tests, Fisher’s exact tests, ANOVA or Kruskal–Wallis tests, as appropriate. p = 0.048 and post hoc p = 0.018, respectively). The short TFR group contained more patients with multilobar GB and incomplete first resection than the long TFR group . The short TFR group contained more patients with short courses of adjuvant TMZ treatment than the intermediate TFR and long TFR groups . GB with methylated MGMT promoters were more frequent in the long TFR group than in the short TFR and intermediate TFR groups .The baseline characteristics of the 338 selected IDH-wildtype GB patients are shown in ®), 206 patients (60.9%) underwent systemic treatment alone and 18 patients (5.3%) were included in clinical trials. There were six principal systemic treatment regimens: TMZ rechallenge, nitrosourea monotherapy and bevacizumab alone or combined with TMZ, nitrosourea or irinotecan. Lomustine was the principal nitrosourea, used in 81.7% of cases. There was no significant difference in second-line options between the three TFR-based groups (p = 0.357), but systemic treatment regimens differed significantly between the long TFR group and the short TFR and intermediate TFR groups   had supportive care and 301 patients (89.1%) received treatment after the first progression. Of the 301 patients treated, 12 (3.6%) underwent repeat radiotherapy, 65 patients (19.2%) underwent reoperation, including 26 (7.7%) who received intratumoral treatment consisting of carmustine-releasing wafers (Gliadelctively) . TMZ or The 338 patients had a median PFS1 of 7.8 months (95% CI: 6.8–8.6) and a median OS1 of 19.8 months (95% CI: 18.5–22.0) . After sp < 0.001), OS1 (p < 0.001), PFS2 (p < 0.001) and OS2 (p = 0.011) values (p < 0.001) and intermediate TFR groups (13.6 months (95% CI: 12.2–14.9); post hoc p < 0.001) (p < 0.001) (p < 0.001) and intermediate TFR groups (22.9 months (95% CI: 21.2–25.1); post hoc p < 0.001) (p < 0.001) (p < 0.001) and long TFR groups (7.0 months (95% CI: 5.5–9.1); post hoc p < 0.001) (p = 0.155). OS2 in the long TFR group (13.0 months (95% CI: 11.2–17.7)) was significantly longer than that in the short TFR (9.5 months (95% CI: 8.3–11.2); post hoc p = 0.027) and intermediate TFR groups (8.5 months (95% CI: 6.7–9.3); post hoc p = 0.005) (p = 0.242).The short TFR, intermediate TFR and long TFR groups had significantly different PFS1  values . Post-ho< 0.001) A. The PF< 0.001) A. Simila< 0.001) B. OS1 in< 0.001) B. PFS2 i< 0.001) C. PFS2 d= 0.005) C. OS2 dip = 0.001), multilobar tumor (p = 0.008), unmethylated MGMT (p < 0.001), short period of TMZ consolidation treatment (p < 0.001), short PFS1 (p < 0.001), short or intermediate TFR (vs. long TFR) (p < 0.001), short PFS2 (p < 0.001) and the supportive care option (p < 0.001) (p = 0.010), unmethylated MGMT (p < 0.001), short or intermediate TFR (vs. long TFR) , short PFS2 (p < 0.001) and the supportive care option (p < 0.001)  . Five va< 0.001) .p = 0.007) and the supportive care option (p < 0.001) (p < 0.001) (p < 0.001) .TFR was significantly positively correlated with PFS1, the number of cycles of adjuvant TMZ and MGMT methylation status . No corr< 0.001) . One var< 0.001) . The OS2< 0.001) . Older a®. It was not possible to stratify these two analyses for TFR due to the small number of patients with intermediate or long TFR.Given the diversity of second-line treatments, two main analyses were conducted: one to compare systemic treatment with and without reoperation and the other to compare the efficacy of repeat surgery with and without the intratumoral treatment with Gliadel® treatment were excluded from the analysis. The characteristics of the patients retained for the analysis are shown in p = 0.027 for all comparisons). Reoperation was more frequent in the nitrosourea group than in the bevacizumab and bevacizumab plus nitrosourea groups . Reoperation rates were also higher in the TMZ group than in the bevacizumab group (post hoc p = 0.023). The TFR of the bevacizumab plus nitrosourea group was significantly different from those of the TMZ (post hoc p = 0.004) and bevacizumab plus TMZ (post hoc p = 0.046) groups, the bevacizumab plus nitrosourea group having fewer patients with a long TFR.We considered the six systemic treatments most frequently prescribed: TMZ rechallenge, nitrosourea monotherapy and bevacizumab alone or combined with TMZ, nitrosourea or irinotecan. Patients who underwent repeat radiotherapy or reoperation with intratumoral Gliadelp = 0.841, p = 0.945, p = 0.641 and p = 0.690, respectively)  (p = 0.009) (p < 0.001) and bevacizumab plus TMZ groups (34.6 months (95% CI: 17.3–NA); post hoc p = 0.016) (p = 0.238), although there was a trend towards longer PFS2 in the groups receiving bevacizumab (p = 0.042) (p = 0.034). OS2 did not differ significantly between the TMZ and other treatment groups. Median OS2 was 10.6 months (95% CI: 8.2–14.2) in the nitrosourea group, 9.9 months (95% CI: 7.5–18.7) in the bevacizumab group, 12.4 months (95% CI: 10.1–NA) in the bevacizumab plus TMZ group and 10.8 months (95% CI: 9.1–17.4) in the bevacizumab plus irinotecan group.Patients receiving systemic treatment without reoperation had a median PFS1 of 6.7 months (95% CI: 6.5–7.9), a median OS1 of 20.5 months (95% CI: 18.5–23.0), a median PFS2 of 6.0 months (95% CI: 5.4–6.9) and a median OS2 of 10.8 months (95% CI: 9.4–12.0) . Reoperactively) . PFS1 anctively) . Post ho= 0.009) . OS1 in = 0.016) . The use= 0.016) . PFS2 diacizumab . Median = 0.042) . Post hon = 32) from the previous analysis were compared with patients undergoing reoperation with intratumoral Gliadel® treatment . The characteristics of the selected patients are shown in ®, 9 patients (34.6%) also received systemic treatment. Patients who underwent reoperation and received systemic treatment . PFS1, OS1, PFS2 and OS2 did not differ significantly between these two groups  (® group had a median PFS1 of 8.6 months (95% CI: 5.9–12.2), a median OS1 of 24.4 months (95% CI: 18.3–33.0), a median PFS2 of 5.9 months (95% CI: 4.5–8.7) and a median OS2 of 14.8 months (95% CI: 8.1–21.4).Complete resection of the primary and recurrent tumors was more frequent in the reoperation plus Gliadelctively) . The reon = 42) were on the standard six-cycle regimen and that 25 patients (59.5%) received adjuvant TMZ treatment for a prolonged period, indicating that a reasonable proportion of patients on standard maintenance therapy may have a long TFR.There is no widely accepted approach for managing rGB after TMZ chemoradiotherapy. The second-line option is, therefore, based on the preferences of the treating center, the individual characteristics of the patient and tumor aggressiveness, which can be assessed by determining TFR after chemoradiotherapy ,19. In tThe 338 GB patients included in this retrospective study had a median OS1 after first surgery of 19.8 months and a median OS2 after first progression of 9.9 months; these values are typical for GB patients in the Stupp era ,24,25. TA multivariate Cox regression analysis of factors associated with OS2 showed that the supportive care option after first progression was a significant independent predictor of shorter OS2. Being older, male and having a short TFR also tended to be independent predictors of poor OS2. The survival disadvantage of these factors after progression has already been highlighted in other studies ,24,26,27The decision to give supportive care rather than treatment after a first progression is generally based on rapid progression of the GB associated with comorbid conditions and/or a worsening of neurological state. Older age, contraindications for alternative options or the patient’s refusal to prolong therapy may also underlie the decision to implement supportive care. Systemic treatment alone was the most common second-line treatment recorded in the FGB, this treatment being administered to 206 patients (60.9%). Repeat radiotherapy was performed in only 12 patients 3.6%). This treatment option may continue to be limited because unanswered questions remain about the efficacy and toxicity of a second course of radiation, even with improvements in the techniques used, such as stereotactic radiosurgery and stereotactic radiotherapy . Reopera.6%. This® treatment and rGB patients undergoing reoperation and receiving systemic treatment (median OS2: 14.8 vs. 10.4 months). The benefits of repeat resection after the first recurrence remain unclear from published data [n = 167). Median OS from randomization was 9.2 months and 8.7 months, respectively. Furthermore, similar to Jakobsen et al. [Given the small number of patients with intermediate or long TFR, all 338 GB patients selected from the FGB database were included in the analysis of second-line treatment efficacy. This analysis showed that reoperation before the use of systemic treatment did not increase survival. Median OS2 was 10.4 for the reoperated and 10.8 months for the non-reoperated groups. Similarly, there was no significant difference in survival between rGB patients undergoing reoperation with intratumoral Gliadelhed data . Some sthed data ,36,37. Ahed data ,38,39. Fhed data  and a phhed data —showed thed data  showed, hed data , who evan et al. , we founn et al. . The autn et al. ,46,47. IAll of our data are consistent with the findings of recent studies ,11. TheyThis study has several limitations. It was a retrospective analysis with only small numbers of patients per group for group analyses, which may, therefore, have been subject to several unavoidable biases. Immunohistochemistry for IDH1-R132H was the only technique used for assessment of the IDH status of the tumors. Sanger sequencing for IDH1/2 genes was not systematically performed for all cases. It was not possible to assess the impact of MGMT methylation status on OS1 and OS2 because of the large amounts of missing data. An analysis of MGMT methylation status is not mandatory for routine pathology reports in the FGB network because of its minimal relevance to clinical decision-making for first-line treatment. However, knowledge of MGMT methylation status might be useful for decisions concerning second-line treatment ,48. AnotWithin the FGB, four treatment options for rGB patients were recorded: repeat radiotherapy, reoperation, systemic treatment and inclusion in a clinical trial. Systemic treatment was the option most frequently selected for rGB patients, with bevacizumab plus nitrosourea more frequently used in patients with a short or intermediate TFR and TMZ rechallenge and bevacizumab plus TMZ more frequently used in patients with a long TFR. None of the systemic treatment regimens was unequivocally better than the others for second-line therapy. Reoperation before the administration of systemic treatment did not increase survival. Survival was best for patients with a long TFR, but these patients accounted for only a small proportion of the study population (13.0%). This better survival appeared to be more strongly associated with response to first-line treatment than with response to second-line treatment, indicating that the recurring tumors were more aggressive and/or resistant than the initial tumors in these patients. There is an urgent need for molecular investigations of the reasons for which some GB patients have a long TFR after chemoradiotherapy. With the exception of MGMT methylation status, the few studies focusing on the molecular characteristics of IDH-wildtype GB from patients in the short and long survival groups failed to identify a solid long-term survivor signature at either the genomic or transcriptomic level . Additio


Located in southwestern Indian Ocean, Mayotte is a French territory, with a very specific demographic, social and health context. To date, epidemiological data on infections by hepatitis B (HBV), C (HCV), and delta (HDV) viruses in Mayotte have been sparse. We aimed to estimate, in the 15–69-year-old general population living in Mayotte, the prevalence of infections by hepatitis B (HBV), C (HCV), and delta (HDV) viruses and the distribution of HBV status: current infection with positive HBs antigen (Ag); resolved infection with positive HBc antibodies and negative HBsAg; immunisation by vaccination with only positive HBs antibodies; and no infection/no immunisation with negative markers. We also described the characteristics of infected people and assessed the determinants of lifetime HBV infection.The Unono Wa Maore survey, implemented in a random sample of the general population in 2018–2019, consisted of an at-home collection of epidemiological data and venous blood samples. Detection of hepatitis B, C, and delta serological and molecular markers was performed.Among 5207 eligible people, 4643 responded to the questionnaire (89.2%), with 2917 being tested for HBV and HCV (62.8%). Estimated HBV status was as follows: current infection 3.0%  (n = 76); resolved infection 27.8% (95% CI: 25.8–29.9); immunisation by vaccination 27.7% (95% CI: 25.9–29.7); and no infection/no immunisation 41.5% (95% CI: 39.3–43.7). One participant was positive for HDV antibodies (Ab) (0.65%) with a negative HDV-RNA viral load. The risk of lifetime HBV infection was higher in men : 1.55, 95% CI: 1.29–1.89); in people aged 30–49 years  or 50–69 years  compared to those under 20; in individuals who reported no condom use during their first sexual intercourse ; and in those living in Dembeni-Mamoudzou  compared to the West-Centre of Mayotte. Finally, six individuals were positive for HCV antibodies (0.21%), including three positive for HCV RNA.Mayotte is an area of intermediate endemicity for HBV and low endemicity for HCV and HDV. With a prevalence of HBsAg 10 times higher than in mainland France, a high proportion of people susceptible to HBV infection, and a demographic, health, and social context that may favour its transmission, hepatitis B is a major public health concern in Mayotte. The HBV-DNA viral load (detectable for 99%) was less than 2000 IU/ml, between 2000 and 20,000 IU/mL, and greater than 20,000 IU/mL for 64.0%, 23.2%, and 11.8% of people, respectively (Table %. The HB–3) as well as in participants born in the Comoros (33.1%) than in Mayotte (21.5%), France (excluding Mayotte) (3.5%), or another country (22.3%). The proportion of those with a resolved HBV infection reached 50.5% among 50–69 year-old participants.The proportion of the population living in Mayotte aged 15–69 years with a resolved HBV infection was estimated at 27.8% (95% CI: 25.8–28.9). This proportion varied significantly according to the studied characteristics with the exception of health insurance coverage, reported anti-HBV vaccination status, and precarious housing  was 30.8% (95% CI: 28.7–32.9). In multivariate analysis, the risk of lifetime HBV infection was significantly higher in men [aPR: 1.55 (95% CI: 1.29–1.86)] and in people aged 30–49 [aPR: 3.83 (95% CI: 1.49–9.81)] or 50–69 years [aPR: 4.52 (95% CI: 1.77–11.53)] compared to those aged under 20  or in other countries [aPR: 0.57 (95% CI: 0.37–0.86)] compared to those born in Mayotte. People living in Dembeni-Mamoudzou [aPR: 1.40 (95% CI: 1.09–1.80)] had a higher risk of having been infected compared to those living in the West-Centre of Mayotte, as well as those living in Petite-Terre though it was not statistically significant. Regarding sexual behaviour, the risk of having been infected with HBV was significantly higher in individuals who reported not using a condom during their first sexual intercourse [aPR: 1.46 (95% CI: 1.01–2.14)] compared to those who declared using one.The proportion of people immunised by vaccination in the 15–69-year-old population living in Mayotte was estimated at 27.7% (95% CI: 25.9–29.7) and varied significantly according to the investigated variables ] were estimated to be negative for all three serological markers and therefore susceptible to infection with HBV and HDV. This proportion reached 47.9% among those under 30 years and 51.3% among those who reported no sexual intercourse in their lifetime.Among the 2917 people screened for HCV antibodies, only six were positive (0.21%). These three men and three women had an average age of 56.3 years . Three people had an active HCV infection (HCV RNA positive), with HCV RNA levels of 4.7, 5 and 5.2 Log IU/mL, respectively. Hepatitis C genotype was 1b, 3h, and 2 (not subtypable).This survey conducted among a large random sample of the general population living in Mayotte enabled us to provide original and robust estimates of hepatitis B, C, and delta prevalence and the distribution of HBV infection status, to identify the determinants of HBV infection and to describe the epidemiological and virological characteristics of people infected with HBV.Current HBV infection prevalence was estimated to be 3.0% 95% CI: 2.3–3.9) in 15–69 year-olds, corresponding to a prevalence 10 times higher than that estimated in the general population in mainland France in 2016 (0.3%) . This is.3–3.9 inOur results suggest that the transmission modes of HBV are varied and that contamination occurs at all ages, as classically described in areas of intermediate HBV endemicity. Indeed, 1.3% of people who declared no sexual intercourse were positive for HBsAg, thus suggesting perinatal or childhood transmission. Conversely, the five times higher prevalence among people who declared not using a condom during their first sexual intercourse points toward sexual transmission. The heterogeneity of the population living in Mayotte, with more than half of adults born abroad , mainly In terms of comorbidities, no cases of co-infection with HIV or HCV were identified, reflecting the limited circulation of these viruses in Mayotte and more widely in the Comoros archipelago , probablThe proportion of people with a resolved HBV infection was estimated at 27.8% (95% CI: 25.8–29.9), increasing sharply with age to reach 51% among 50–69 year-olds. Consequently, more than three in ten people aged 15–69 years living in Mayotte have a lifetime HBV infection (resolved or current). As expected, the risk of lifetime HBV infection in multivariate analysis was significantly higher in men and in people over 30 years (compared to those under 20). More surprisingly, compared to those born in Mayotte, people born in the Comoros were more likely to have been infected during their lifetime in univariate analysis, but this association was not statistically significant after adjustment to other variables, especially gender and age group, in multivariate analysis. This could be explained by significant differences between the age and sex distributions of people born in Mayotte and the Comoros, whereas the proportion of infected people varied greatly according to gender and age group .In this context of significant HBV circulation, the implementation of preventive measures, in particular vaccination, is essential. While the implementation of anti-HBV vaccination at birth , 23 sincBesides the insufficient immunisation rate, the vaccine status against HBV was poorly known by participants, since more than half of the population in Mayotte was estimated to be unaware of their HBV vaccine status. In mainland France, this estimated proportion was 7% in 2016 . Among pFor hepatitis C virus, only six of the 2917 people tested for HCV antibodies were positive (0.21%), including three positive for HCV RNA. This result confirms that Mayotte is a low endemic area for HCV, similarly to mainland France where the prevalence of HCV RNA was estimated at 0.3% among the general population in 2016 .As the objective of the Unono Wa Maore survey was to describe the state of health and health care use for the population living in Mayotte, choices were made to limit the length of time for completing the questionnaires. Thus, the epidemiological data collected on hepatitis were limited and only appeared in the long questionnaire . Therefore, this limited the power of the statistical analyses. Further, comparisons with the results of other health surveys performed in mainland France , 36 mustThis survey conducted among a large random sample of the general adult population confirmed that Mayotte is an area of intermediate endemicity for HBV and low endemicity for HCV and HDV. With a prevalence of HBsAg 10 times higher than in mainland France, a high proportion of unimmunised people, especially young people, and a demographic, health, and social context that may favour its transmission, hepatitis B should be considered as a public health priority in Mayotte. In this perspective, implementing vaccination catch-up campaigns in adolescents and young adults, strengthening screening for hepatitis B in men, as well as promoting preventive sexual behaviours are among the priority actions to be carried out.


In end-stage kidney disease, patients may undergo parathyroidectomy if secondary hyperparathyroidism cannot be managed medically. This study was designed to estimate the parathyroidectomy rate in the United States (US) and to quantify changes in costs and other outcomes after parathyroidectomy.This was a retrospective observational cohort study using US Renal Data System data for 2015–2018. Parathyroidectomy rates were estimated for adult hemodialysis and peritoneal dialysis patients alive at the beginning of 2016, 2017, and 2018 who were followed for a year or until parathyroidectomy, death, or transplant. Incremental differences in economic and clinical outcomes were compared before and after parathyroidectomy in adult hemodialysis and peritoneal dialysis patients who received a parathyroidectomy in 2016 and 2017.The rate of parathyroidectomy per 1,000person-years decreased from 6.5 (95% CI 6.2-6.8) in 2016 to 5.3 (95% CI5.0-5.6) in 2018. The incrementalincrease in 12-month cost after versus before parathyroidectomy was $25,314. By the secondmonth after parathyroidectomy, 58% of patients had a corrected calcium level< 8.5 mg/dL. In the year afterparathyroidectomy (versus before), hospitalizations increased by 1.4 perperson-year (95% CI 1.3-1.5), hospital days increased by 12.1 per person-year(95% CI 11.2-13.0), dialysis visits decreased by 5.2 per person-year (95% CI4.4-5.9), and office visits declined by 1.3 per person-year (95% CI1.0-1.5). The incremental rate per 1,000person years for hematoma/bleed was 224.4 (95% CI 152.5-303.1), for vocal cordparalysis was 124.6 (95% CI 59.1-232.1), and for seroma was 27.4 (95% CI0.4-59.0).Parathyroidectomy was a relatively uncommon event in the hemodialysis and peritoneal dialysis populations. The incremental cost of parathyroidectomy was mostly attributable to the cost of the parathyroidectomy hospitalization. Hypocalcemia occurred in over half of patients, and calcium and phosphate levels were reduced. Clinicians, payers, and patients should understand the potential clinical and economic outcomes when considering parathyroidectomy.The online version contains supplementary material available at 10.1186/s12882-022-02848-x. Patients with end-stage kidney disease (ESKD) often have secondary hyperparathyroidism (SHPT) which is characterized by elevated parathyroid hormone (PTH) in response to kidney failure. SHPT is commonly associated with mineral and bone disorder (MBD) which includes associated effects on serum levels of calcium (Ca) and phosphate (P) .TypicallParathyroidectomy is relatively uncommon. The rate of parathyroidectomy was estimated at 5.4 per 1,000 person-years using United States (US) inpatient data from 2002 through 2011 and was relatively stable through the latter part of the time period . The autTherefore, the goals of this study were to provide more current estimates of the parathyroidectomy rate in adult, US hemodialysis (HD) and peritoneal dialysis (PD) patients, and to quantify changes in costs as well as key outcome measures after parathyroidectomy, including subsequent parathyroidectomy, mortality, surgical side effects, dialysis visits, office visits, hospitalizations, and selected laboratory values.Please see Supplementary Materials for more details on the methods used in this study.This was a retrospective observational cohort study using USRDS data from January 1, 2015 through December 31, 2018 . SpecifiFor the parathyroidectomy rate analyses, the study index date was January 1 of each year from 2016–2018. The baseline period was the 3-month period prior to January 1 and follow-up ended on December 31 of each year. For the parathyroidectomy cost and outcomes analyses, the baseline period was the 12-month period prior to parathyroidectomy; follow-up began with the parathyroidectomy and ended on December 31, 2018.For all analyses, follow-up was truncated at the following events: end of continuous Medicare Part A, B, and D enrollment, kidney transplant, death, or the end of the data . For the parathyroidectomy rate analyses, follow-up was also truncated at parathyroidectomy.For the parathyroidectomy rate analyses, we included all prevalent HD and PD patients age 18 years or older as of the first day of each year from 2016 through 2018. Patients must have been continuously enrolled in Medicare Part A and Part B coverage with Medicare as the primary payer and must not have received a parathyroidectomy during the baseline period.For the parathyroidectomy cost and outcomes analyses, the study population was all adult HD and PD patients who underwent parathyroidectomy between January 1, 2016 and December 31, 2017 who were at least 19 years old at the time of parathyroidectomy and received either HD or PD (but not both) during the entire 12-month baseline period. Patients receiving HD must have received at least 21 HD visits over the previous 3 months . Patients must have had Medicare Part A, Part B, and Part D coverage during the entire baseline period. We excluded patients who had a prior parathyroidectomy during the observation period  as well as patients with a diagnosis code for primary hyperparathyroidism who had no diagnosis of secondary hyperparathyroidism.For parathyroidectomy rate estimation, the key baseline variables were age, sex, dialysis modality, and ESKD network. For the parathyroidectomy cost and outcomes cohort, additional baseline variables included time since dialysis initiation (vintage), cause of ESKD, and comorbid conditions. Comorbid conditions were based on the Charlson Comorbidity Index, excluding renal disease . PhosphaFor parathyroidectomy rate estimation, the outcome was based on the parathyroidectomy date of service. Costs were defined as Medicare payment and patient contracted amounts  for all covered services, adjusted to 2020 using the full-year 2020 medical component of the Consumer Price Index. Resource utilization included dialysis visits, hospitalization, hospitalization days, and office visits. Surgical side effects were based on diagnosis codes for vocal cord paralysis or laryngeal nerve injury, hematoma/bleeding related to surgery, wound infection related to surgery, and seroma formation related to surgery . JigsawThe rate of parathyroidectomy per 1,000 person-years decreased during the 3 years of observation in this study from 6.5 95% CI 6.2 to 6.8) in 2016 to 5.8 (95% CI 5.5 to 6.1) in 2017 to 5.3 (95% CI 5.0 to 5.6) in 2018. Over this 3-year time period, the annual rate ranged from 4.9 to 6.1 in HD patients and from 8.8 to 10.4 in PD patients. Over the time period, the highest rate in any stratum was for patients younger than 40 years of age, which ranged from 19.3 to 21.9. Detailed results by year and by modality, race, and vintage are provided in Fig.  to 6.8 iThe process of creating the cohort is described in Supplementary Materials Table The incremental difference in the paid amount (rounded to the nearest dollar including payer and patient amounts) between the year after and the year before parathyroidectomy was $25,314  in the rate per 1,000 person years for hematoma or bleed was 224.4 (95% CI 152.5 to 303.1). The incremental rate for vocal cord paralysis was 124.6 (95% CI 59.1 to 232.1). The incremental rate for seroma was much lower, at 27.4 (95% CI 0.4 to 59.0). We identified no wound infections in the cohort.The incremental differences in the utilization rate per person-year (after parathyroidectomy minus before) for office visits, dialysis visits, and hospitalizations are provided in Table Monthly median cCa and P were stable in the 12 months prior to parathyroidectomy but varied over time after parathyroidectomy Fig. . The ratThis study presents the most current parathyroidectomy rates to date and is the first to provide detailed cost, utilization and laboratory information for the year before and after parathyroidectomy. Parathyroidectomy remains a relatively uncommon event for dialysis patients. The rate of parathyroidectomy per 1,000 person years declined from 6.5 to 5.3 between 2016 and 2018; however, it is difficult to extrapolate long-term trends from 3 years of data. These rates are slightly higher than the overall rate of 5.4 per 1,000 estimated by Kim et al. using annual inpatient data from 2002 to 2011 [Patients undergoing parathyroidectomy cost the healthcare system an incremental $25,000, the majority of which is from inpatient facility payments for the parathyroidectomy itself but which also includes the higher rate of hospitalization and hospitalization days during the 12 months afterward. The incremental cost of parathyroidectomy was even higher in PD patients . In terms of other consequences of parathyroidectomy, both subsequent parathyroidectomy and all-cause mortality were at their highest levels during the 30-day period after the parathyroidectomy. The higher mortality after surgery is consistent with the findings from Kestenbaum, et al., although the absolute rate in that study  is more than twice the rate in our study .  Since Belozeroff et al. showed that hypocalcemia was the most common surgical complication, followed by bleeding, and that wound infection and seroma were rare . Our stuWe also showed that inpatient hospitalizations increased by 1.4 per person per year and hospital days increased by 12.1 days per person per year. Given that outpatient HD occurs on 3 out of 7 days (43%), one would expect exactly 5.2 fewer dialysis visits with 12.1 more days in the hospital. Hence, the increase in hospitalizations likely explains the lower rate of dialysis visits.Patients who undergo parathyroidectomy are a select subgroup of patients with SHPT. At the time of parathyroidectomy in our 2016–2017 parathyroidectomy cohort, 47% of patients were receiving phosphate binders, 47% were receiving IV vitamin D, and 43% were receiving calcimimetics. In comparison, in the overall ESKD population in quarter 1 of 2017, 63% of patients were receiving phosphate binders, 42% were receiving IV vitamin D, and 30% were receiving calcimimetics .This study is strengthened by its broad coverage of US dialysis patients, the availability of detailed laboratory information, and the availability of comprehensive Medicare claims data that include direct health care expenditures across all settings of care . As with any study using observational data, there are limitations and other factors to be considered when interpreting these findings. Our focus was on HD and PD patients who had Medicare as their primary payer. Our rates were estimated for 2016–2018, and our parathyroidectomy cohort was limited to patients who had a parathyroidectomy in 2016–2017. When estimating the annual parathyroidectomy rates, it is likely that some procedures were not the “first-ever” parathyroidectomy for some patients. However, because we excluded patients who had a parathyroidectomy within the 3 months prior to each year, we minimized the potential for double-counting parathyroidectomy episodes. Also, we were not able to evaluate whether changes in the parathyroidectomy rate were associated with changes in vitamin D or calcimimetics use because oral medication data were only available in patients with Medicare Part D coverage. Finally, we note that these results apply to the US and that in other regions of the world parathyroidectomy utilization and practice patterns may be different.The cohorts created in this study only included patients with Medicare fee-for-service coverage. However, since commercially insured patients initiating dialysis are covered by their primary private insurer during a 36-month coordination of care period and are not included in these data, these results may not apply to the full dialysis population. As a result, in both the parathyroidectomy rate and cost estimation analyses, there is a risk that younger patients in our study may be different from the total under-65 years of age population initiating dialysis. Also, because different kinds of costs including medications are reimbursed as part of the bundled dialysis payment, we could not separate all medication costs from medical costs. Similarly, costs by type may vary depending on the specific details of the bundled payments for a particular year. As a result, cost increases for medications used to manage patients after parathyroidectomy  cannot be enumerated in this study. Also, to the extent that parathyroidectomy might reduce the risk and associated cost of long-term outcomes beyond one year, these analyses could not capture the associated cost reductions. Finally, we did not have parathyroid hormone levels in the data, which would have been useful for characterizing the short-term and long-term effectiveness of parathyroidectomy.In conclusion, parathyroidectomy is a relatively uncommon event that continues to occur at a rate of about 5.3 to 6.5 per 1,000 person-years. The incremental 12-month cost of parathyroidectomy is approximately $25,000, and the most common complication of surgery is the risk of hypocalcemia which occurs in more than half of patients. Both mean cCa and P decline after surgery and, although they rise during the following year, they remain lower than the presurgical values. Because of the implications of parathyroidectomy for clinicians, payers and patients, the USRDS should consider reporting parathyroidectomy-related metrics in its annual report. This would facilitate clear communication of the clinical and economic outcomes associated with parathyroidectomy.Additional file 1: Supplemental Table 1.  Diagnosis codes for surgical side effects. Supplemental Table 2.  Rate of Parathyroidectomy Overall and Within Strata: 2016. Supplemental Table 3.  Rate of Parathyroidectomy Overall and Within Strata: 2017. Supplemental Table 4. Rate of Parathyroidectomy Overall and Within Strata: 2018. Supplemental Table 5. Poisson Regression Model of Factors Associated with Parathyroidectomy. Supplemental Table 6. Parathyroidectomy Cohort Attrition Table13. Supplemental Table 7.  Costs Before and After Parathyroidectomy, Overall and by Dialysis Modality:  Sensitivity Analysis. Supplemental Figure 1. Total Payments by Type (All Patients Using Censoring Weights). Supplemental Figure 2. Office Visit Utilization Over Time Supplemental Figure 3. Hemodialysis Visits Over Time. Supplemental Figure 4. Hospitalizations Over Time


Anastomotic leakage (AL) and surgical site infection (SSI) account for most postoperative complications in colorectal surgery. The aim of this retrospective trial was to investigate whether perioperative selective decontamination of the digestive tract (SDD) reduces these complications and to provide a cost-effectiveness model for elective colorectal surgery.All patients operated between November 2016 and March 2020 were included in our analysis. Patients in the primary cohort (PC) received SDD and those in the historical control cohort (CC) did not receive SDD. In the case of rectal/sigmoid resection, SDD was also applied via a transanally placed Foley catheter (TAFC) for 48 h postoperatively. A propensity score-matched analysis was performed to identify risk factors for AL and SSI. Costs were calculated based on German diagnosis-related group (DRG) fees per case.P = 0.016). SSI occurred in 14 patients (9.1%) in the PC and 30 patients in the CC (19.5%), representing a significant reduction in our SSI rate (P = 0.009). The cost-effectiveness analysis showed that SDD is highly effective in saving costs with a number needed to treat of 12 for AL and 10 for SSI.A total of 308 patients (154 per cohort) with a median age of 62.6 years (IQR 52.5–70.8) were analyzed. AL was observed in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC (OR 0.380, 95% CI 0.174–0.833; SDD significantly reduces the incidence of AL and SSI and saves costs for the general healthcare system.The online version contains supplementary material available at 10.1007/s00423-022-02540-6. The field of colorectal surgery has experienced magnificent improvements over the last decades. As a result, colorectal cancer has become one of the domains of surgical oncology with outstanding chances of complete cure . FurtherThe indication for modern preoperative mechanical bowel preparation (MBP) either alone or in combination with oral antibiotics  to prevent the aforementioned complications has been a subject of ongoing controversy since its introduction in the 1970s , 4. The Recent studies have shown that selective decontamination of the digestive tract (SDD) using topical antimicrobial agents has a positive effect on the rate of anastomotic leakage. A reduction in anastomotic leakage could be demonstrated for both upper gastrointestinal tract   and loweBased on the promising evidence, perioperative SDD was implemented at our institution in September 2018 for all elective colorectal procedures. We aimed to determine the association between this change in preoperative procedure and occurrence of AL and SSI with regard to our postoperative management.This report demonstrates the influence of MBP with SDD on the outcome of patients who received conventional or minimally invasive elective colorectal resection for benign and malignant diseases. In addition, a cost-effectiveness analysis was performed.This retrospective study was approved by the local institutional review board  comprising patients who received our regimen between September 2018 and March 2020 and a historic control cohort (CC) without standardized MBP operated between November 2016 and August 2018. Prior to the introduction of OABP and MBP, only patients with planned rectal resection received full MBP. Sigmoid and left-sided resection only had a transanally applied enema prior to surgery. Right-sided and transverse colonic resections did neither take OABP nor MBP. During the observation period, there was no change in suture material (PDS 4–0 or 5–0) or stapling device.Operations were performed or supervised by an experienced, certified colorectal surgeon. All patients were treated according to enhanced recovery after surgery (ERAS) principles . ClinicaAll patients received perioperative intravenous antibiotics of cefuroxime 1.5 g and metronidazole 500 mg 30 min up to 1 h before surgery and repeated every 2 and a half hours after informed consent. In the case of allergy to cefuroxime, clindamycin 600 mg was given and repeated every 2 h. No postoperative intravenous antibiotics were routinely administered. The day before surgery, mechanical bowel preparation was performed using 3 l of solution for gastrointestinal lavage . The ingredients are shown in Supplementary Table The SDD medication was prepared by our clinic pharmacy with a stability-approved protocol according to the pattern used in SELECT trial expanded by vancomycin , 12. A cIn case of postoperative diarrhea, routine testing towards clostridium dificile toxin A/B was applied.AL was defined according to the International Study Group of Rectal Cancer as a defect of the entire intestinal wall at the anastomotic suture line resulting in communication between the intra- and extraluminal spaces, detected by means of endoscopy, radiological contrast enema, thin layer CT, or surgery . The comThe Centers for Disease Control and Prevention define surgical site infection as infection that occurs at the incision site within 30 days after surgery, is limited to the cutis and subcutis, and requires reopening or treatment . AdditioFor mechanical bowel preparation, 3 l of coloscopy solution (Klean-Prep®) are used at a price of €3.53 per liter for a total of €10.59. The price of vancomycin is €13.53 for 1 vial of 500 mg, from which 125 mg is withdrawn. Patients without a TAFC require three doses (€10.15) and those receiving a TAFC need 11 (€37.21) doses of vancomycin. The cost of SDD suspension is €4829.20 for 100 bottles (containing 40 ml). One application contains 10 ml, so every patient without TAFC needs one bottle and patients with TAFC need three bottles. This finally comes to €58.44 for patients without a TAFC and €182.09 for those with a TAFC. In total, our regimen with bowel preparation and SDD solution costs €69.03 for patients without a TAFC and €192.68 for those with a TAFC.The standardized payments and weights of the German diagnosis-related group (G-DRG) system were used to calculate the total cost of hospital stay plus readmission.t test or the Wilcoxon rank sum test. Dichotomous data were compared using the χ2 test. All variables with P < 0.1 were included in a stepwise backward multivariate logistic regression model adjusting for age, sex, BMI, and ASA. Results were reported as odds ratios (OR) and 95% confidence intervals (95% CI). No adjusting for multiple testing was applied. A P value < 0.05 was considered statistically significant. The number needed to treat was calculated as 1/absolute risk reduction. The absolute risk reduction was the difference between the event rates in the PC and CC. Statistical analyses were carried out using IBM SPSS Statistics v23 .Due to the retrospective character of the reported data, the sample size was not chosen based on a power calculation. Propensity scores for both the primary and control cohort were calculated with a multivariate logistic regression model including 14 variables (see Supplementary Table P = 0.012). The main indication for surgery in both cohorts was a tumor in 116/154 (75.3%) and 114/154 (74.0%) patients in the PC and CC, respectively. This was followed by inflammatory bowel disease  in 21/154 (13.6%) patients in the PC and 22/154 (14.3%) in the CC. Reconstruction after Hartmann’s procedure was performed in 11/154 (7.1%) patients in the PC and 12/154 (7.8%) patients in the CC  were selected via propensity score analysis. The median age was 63.1 (IQR 54.8–70.8) years in the PC and 61.9 (IQR 51.9–71.9) years in the CC. Body mass index (BMI) was the same in both the PC  and CC . The two cohorts did not differ in most of the investigated base line parameters. However, there was a significant difference in terms of previous abdominal operations, including gall bladder and hernia operations. Patients in the PC had previous surgery in 66/154 (42.9%) cases, whereas those in the CC received previous abdominal surgery in 88/154 (57.1%) cases  patients in the PC and 107 (69.5%) in the CC underwent colonic surgery, and 51 (33.1%) patients in the PC and 47 (30.5%) in the CC had rectal resections. The most common operations were right hemicolectomy with 42 operations in the PC (27.2%) and 34 (22.1%) in the CC, followed by rectal and sigmoid resections in 19 (12.3%) patients in the PC and 25 (16.2%) in the CC. Multivisceral resection was necessary  in 20 (13.0%) patients in the PC and 24 (14.3%) in the CC. Two anastomoses were performed on nine patients in the PC (5.8%) and six patients in the CC (3.9%). Three anastomoses to the colon were carried out in two patients in the CC (1.3%) and 0 patients in the PC. A minimally invasive approach was used in 80 patients in the PC (51.9%) and 74 patients in the CC (48.1%). One hundred sixteen (75.3%) patients in the PC and 114 (74.0%) in the CC have been operated due to a tumor (Table P = 0.133). Additionally, the Clavien-Dindo score is reported (Table Postoperative morbidity was 25.3% in the PC and 33.1% in the CC (P = 0.017). In our CC, 31 patients (20.1%) required redo surgery, whereas in the PC, only 20 patients (13.0%) needed surgical reintervention. The reason for reoperation was mainly due to AL , but also four patients with postoperative bleeding in CC. In total, SSI  and burst abdomen due to SSI  were the main reasons for repeated surgery (Table P = 0.092).AL occurred in ten patients (6.5%) in the PC and 23 patients (14.9%) in the CC, which represented a significant reduction , and one newly generated anastomosis.P = 0.009).SSI occurred in 30 patients in the CC (19.5%) and 14 patients (9.1%) in the PC, which resulted in a significant reduction in our SSI rate (P = 0.101) nor for SSI (P = 0.843). Subgroup analysis also showed no influence on AL and SSI for malignant/benign and inflammatory vs. not inflammatory disease.The individual surgeon’s qualification (certified or not) had no influence on postoperative outcome, neither for AL (P < 0.001). Of the patients with SSI, 5 out of 44 (11.4%) were readmitted to the hospital compared to 14/264 patients (5.3%) without SSI (P = 0.122).Hospital readmission occurred in 6/275 (2.2%) patients without AL and in 13/33 (39.4%) patients with AL  in the CC and 0% in the PC.P = 0.017; multivariate: OR 0.380, 95% CI 0.174–0.833; P = 0.016) , previous operations (P = 0.003), and other surgical complications (P < 0.001) were associated with higher SSI rates. Patients with higher preoperative albumin (P = 0.002) and stool diversion (P = 0.011), who had undergone minimally invasive (laparoscopic or robotic) (P < 0.001) surgery or received SDD, had a significantly lower incidence of SSI. Multivariate analysis found minimally invasive operations  and high albumin levels  to be associated with a reduced rate of SSI. An additional surgical complication was the strongest predictor of SSI . SDD just failed to reach a level of significance in multivariate analysis (P = 0.057). The results are summarized in Table In univariate analysis, higher ASA scores of 3 or 4 (P = 0.230).In total, 83 patients (53.9%) in the PC received postoperative SDD via a catheter placed over the rectal anastomosis. Seventy-five patients (48.7%) in CC are the equivalent patient cohort with rectal anastomosis to perform a subgroup analysis. In total, 8/83 (9.6%) patients in the PC and 12/75 (16.0%) in the CC developed an AL. Univariate analysis did not reach the level of significance (P = 0.189).In patients with a diverting stoma, 2 out of 44 (4.5%) in the PC and 4 out of 31 (12.9%) in the CC were found to have an AL, which was not statistically significant (P = 0.144) or diverting stoma (P = 0.160). Also no complication or anaphylactic reaction was seen due to catheter placement and SDD application.There was no significant detectable influence of SDD on SSI in the subgroup of patients with a transanally placed catheter , resulting in costs of €4,760,461 for the healthcare system. The median DRG relative weight was 3.55 (IQR 2.8–4.5). Patients without AL were hospitalized for a median of 9.0 days (IQR 8.0–14.0) and those with AL for 28.0 days (IQR 19.5–48.0). Overall, this came to 627 additional hospital days for the AL group. The median hospital merit for one patient with AL corresponds to a DRG weight of 6.25 (IQR 4.6–10.5) at costs of €19,081.00  compared to a DRG weight of 3.41 (IQR 2.8–4.1) at costs of €11,850.00  for non-AL patients. On average, our hospital calculated an additional €7231.00 for every patient with AL. These patients were hospitalized for a median of 19.0 additional days.Patients in the CC did not receive SDD, were hospitalized for a median of 11.5 days (IQR 8.0–20.0), and generated a median DRG weight of 3.55 (IQR 2.8–4.6), resulting in median revenue for the hospital of €12,209.00  per patient. In contrast, the introduction of SDD resulted in a median hospital stay of 9.5 days (IQR 8.0–14.3), a median DRG weight of 3.46 (IQR 2.8–4.0), and the same median revenue of €12,209.00 . In summary, in our SDD group, we saved a median of 2.0 hospital days  at moderate treatment costs for the procedure and medication .With regard to AL, we had 8.5% fewer insufficiencies (PC: 10/154 vs. CC: 23/154) since the introduction of SDD. As expected, AL corresponds to a median DRG weight increase of 2.84. This resulted in extra expenses of approximately €135,000 in our cohort , which might have been prevented with the use of SDD.n = 30) had a median stay of 26.0 days, corresponding to a median DRG weight of 4.71 (IQR 3.1–8.9) and median costs of €15,649.00 . Compared to CC data (30 patients with SSI), the regular use of SDD led to 14 patients with SSI in PC, thus 16 patients less suffered SSI. Taking into account the longer hospital stay of 16 days (IQR 10.0–26.0 days) and higher costs of €3620.00  per patient, SDD led to a cost reduction of €57,920.00 (16 × €3620.00) and we saved 256 hospital days (16 × 16) in our PC. When assuming the costs for SSI, a notification towards a strong bias of other complications  potentially triggering the presence of SSI, needs to be mentioned , corresponding to a DRG weight of 3.49 (IQR 2.8–4.2) and median costs of €12,029.50 . In comparison, patients in the CC with SSI  infections could not be confirmed in our cohort  due to the additional use of vancomycin. Moreover, it has been reported to decrease rather than increase the number of CD infections after colectomy [Enterobacteriaceae and fungi in the colon by using effective broad-spectrum antibiotic agents (colistin and tobramycin) against aerobic and anaerobic bacteria, vancomycin against gram-positive bacteria , and amphotericin B against fungi. In particular, bacteria species that produce enzymes which disturb anastomotic or wound healing , like Enterococcusfaecalis, Pseudomonas aeruginosa, and Serratia marcescens, are effectively reduced. These potentially pathogenic microorganisms are thus prevented from overproducing and disrupting the balance of the gut microbiome [In our study, we demonstrated that SDD in combination with MBP has a high potential to reduce AL and SSI. In addition, we provide a cost-effectiveness calculation which might help to spread the use of SDD in routine clinical practice. In summary, we show that using SDD can help reduce costs significantly. Our results confirm the findings of previous studies on this topic –17. Our olectomy . This riolectomy . What stcrobiome , 19, 25.crobiome .In 2018, nearly 79.3% of surgeons in the USA used oral antibiotics in combination with MBP. The most widely used oral antibiotic regimen was neomycin and metronidazole. In a European survey (2018), only 16.8% of patients with elective left-sided colon and rectal resection received a combination of MBP and oral antibiotics. These numbers highlight the need to establish SDD and MBP more firmly in routine clinical practice –29. WithWe are aware that our study has several weaknesses. The effect of MBP alone cannot be illustrated due to the retrospective character of our data and the different use of MBP in our CC. By using propensity score matching, we tried to generate homogeneous patient cohorts and control for bias. Nevertheless, our data is unicentric and not comparable to that of large multicenter randomized trials in terms of number of patients. However, it represents the average patients of a German university hospital, taking into consideration the need for surgical education, the high numbers of pre-existing illnesses at risk in the patient cohort, and more extensive surgical procedures, often in patients with previous abdominal surgeries.n = 154) can be achieved by using our SDD regimen. Although patients suffering from AL led to higher revenue of over €7000 per patient, in-hospital costs for AL treatment (besides the much longer stay) cannot be calculated and are likely much higher. In short, many patients can be spared the consequences of AL and SSI for little investment and an acceptable NNT of 12 and 10, respectively. We therefore strongly recommend including SDD in the existing bundle of measures to prevent surgical side effects [With regard to our cost analysis, we calculated the maximum amount per single application of SDD based on the official pharmaceutical catalog prices. In practice, the drug prizes for hospitals may be lower, and the costs for SDD and MBP may be less than in our calculation. For the SSI calculations, indirect costs  could not be considered due to lack of data. By using the DRG system to calculate the costs for the healthcare system, only the reimbursement volumes are measured. This might be different to the real costs of the complications, which cannot be measured easily without direct data of medical insurance companies. As indirect costs are difficult to calculate, there is a wide range of costs reported. Since costs in the ambulatory setting are frequently not considered, we focused on hospital costs. With regard to previous reports, a median of €5000 in additional costs can be assumed for every patient with SSI –33. In o effects .SDD in combination with mechanical bowel preparation is a highly effective procedure to reduce the risk of AL and SSI in patients requiring elective colorectal resection and restoration. Due to the high increase in costs and significantly longer hospital stay for patients with AL and SSI after surgery, we highly recommend the standard use of an effective combination of antibiotic and antimycotic drugs  before any elective colorectal operation. In our propensity score-matched cohort of 308 patients, we could demonstrate a remarkable cost-effectiveness analysis, which revealed a high potential for reducing costs for the hospital and healthcare system by shortening the length of hospital stay and reducing complications at moderate treatment costs. More importantly, however, is the improved outcome for patients in terms of hospitalization, immobility, pain, and sick leave. The use of topical SDD via a Foley catheter after colorectal anastomosis is still controversial, and the demonstrated trend in patients receiving diverting stomas towards a reduction of AL may be a topic of further studies.Supplementary file1 (DOCX 17 KB)Below is the link to the electronic supplementary material.