August 2025

This retrospective comparative effectiveness study sought to assess the outcomes of operative and nonoperative management of acute cholecystitis in older adults with multiple comorbidities. Using an instrumental variable analysis of Medicare claims, they found that risk-adjusted operative treatment of acute cholecystitis in older patients with multimorbidity was associated with lower rates of 30- and 90-day readmissions and ED visits, as well as lower cost by 90 days, while mortality rates were similar.

Summary: Older adults (>65 years) with multiple comorbidities account for an increasing proportion of surgical patients and pose a particular challenge for decision making in emergency general surgery. While the benefits of early operative intervention in the management of acute cholecystitis are well-defined in the general adult surgical population, optimal treatment course is less clear in this multimorbid subset of patients, who already carry elevated risks of morbidity and mortality. The goal of this study was to compare the effectiveness of operative and nonoperative management of acute cholecystitis in older adults with multimorbidity.

The authors used Medicare claims data to identify multimorbid Medicare beneficiaries aged 65.5 years and older admitted through the ED with cholecystitis from 2016 to 2018. Operative treatment included laparoscopic and open cholecystectomy, nonoperative treatment included antibiotics with or without percutaneous cholecystostomy tubes. Multimorbidity was defined using established comorbidity sets which delineate specific combinations of comorbidity that affect outcomes in surgical patients, including heart failure, diabetes, liver disease, kidney failure, and others. Patients were excluded if they had gallstone pancreatitis, were treated by a low-volume emergency general surgeon (<5 EGS cases per year), or lacked continuous Medicare Part A and B coverage. The authors employed a variety of statistical methods, most notably, an instrumental variable analysis using a preference-based instrumental variable (PBIV) validated for emergency general surgery with the goal of isolating circumstances for which the decision to operate is in clinical equipoise.

The authors identified 32,527 older adults with multimorbidity and cholecystitis who met inclusion criteria, with a median age of 78.8 years (IQR, 72.4-85.2 years). Overall, 21,728 (66.8%) received operative treatment and 10,799 (33.2%) received nonoperative treatment. They found significantly lower unadjusted mortality rates for patients who underwent operative management at 30 and 90 days (3.7% vs 10.2% at 30 days; P < .001 and 6.3% vs 16.8% at 90 days; P < .001), as well as lower rates of readmission and ED visits, and lower overall cost. Risk-adjusted analyses of all patients demonstrated similar findings, with significantly lower 30-day mortality (RD −0.03; P < .001) and 90-day mortality (RD, −0.04; P < .001). The instrumental variable analysis isolating patients in clinical equipoise demonstrated similar 30- and 90-day mortality risk differences, however these were not statistically significant (30-day RD, −0.02; P = .35 and 90-day RD, −0.03; P = .12). Operative treatment was associated with statistically significant differences in readmissions and ED visits at 30 and 90 days (readmissions: 30-day RD, −0.15; P < .001 and 90-day RD, −0.23; P < .001 and revisits: 30-day RD, −0.09; P < .001 and 90-day RD, −0.12; P < .001). The adjusted cost was significantly lower in the operative group by 90 and 180 days (−$5,495.39; P < .001 and −$9134.67; P < .001). Overall, operative treatment was associated with lower mortality rates in the study population. However, in patients who could have reasonably undergone either treatment course, mortality rates were similar between groups, while readmissions, ED visits, and overall cost were lower were lower in the operative cohort.

This retrospective cohort study examines Medicare claims data, so physiologic parameters are not captured, providing only limited clinical context for surgical decision making. While this study did assess readmissions, postoperative complications were not specifically assessed.

Bottom line: In older patients with multimorbidity for whom the approach to management of acute cholecystitis is uncertain, operative management should be strongly considered, as it is associated with similar mortality, lower readmission rates, and lower cost than nonoperative management.

This multicenter single blinded randomized trial analyzes the impact of normovolemic hemodilution prior to elective cardiac surgery on peri- and post-procedural RBC transfusion requirements.  The study found no notable differences in safety or transfusion requirements. The trial results, therefore, do not support the implementation of normovolemic dilution prior to elective cardiac surgery as a standard practice to decrease transfusion requirements.  
 
Summary: This large multi-center randomized controlled trial investigated if acute normovolemic hemodilution (ANH) could reduce RBC transfusions in elective cardiac surgery patients. The study involved 2,010 patients across 32 centers and 11 countries. Patients were randomly assigned to either the ANH group or a control group. The ANH patients had at least 650 mL of whole blood removed just prior to initiation of cardiopulmonary bypass and replaced with crystalloids to maintain normovolemia. The autologous blood was reinfused after bypass. The control group underwent no blood removal. 
 
The primary outcome was the need for allogeneic RBCs during their hospital stay. Secondary outcomes were 30-day or in-hospital all-cause mortality, bleeding requiring takeback, ischemic events, and AKI. 27.3% of ANH patients and 29.2% of the control patients received blood (RR of 0.93 (95% CI: 0.81–1.07; p=0.34)). There were no significant differences in mortality rates, AKI, or ischemic complications but bleeding requiring takeback occurred slightly more often in the ANH group (3.8% vs. 2.6%). Importantly, there were no major safety concerns associated with the conduct of pre-bypass ANH. 
 
Despite its theoretical benefits, ANH did not substantially protect patients from requiring RBC transfusion post-operatively. This contrasts somewhat with previous meta-analyses and smaller single-center studies that suggested ANH could reduce transfusion requirements.  One possible reason for the observed discrepancy is that the absolute difference in transfusion rates was small (27% vs. 29%), and strict transfusion protocols across study sites may have influenced the overall results. Additionally, while this trial was well-powered for the primary outcome, it may not have been large enough to detect differences in rare events such as stroke or myocardial infarction. 
 
This study is not without limitations: The trial was single-blind, with clinicians who were ultimately aware of group assignments that may have influenced transfusion decisions. Blood collection and replacement also varied between centers, and outcomes beyond 30-days or discharge were not studied. Finally, the findings in this low-risk group may not apply to higher risk, emergent, complex, redo, or pediatric patient populations.  
 
Bottom Line: In elective cardiac surgery, ANH did not significantly reduce transfusion rates compared to usual care, though it was shown to be safe. While ANH is theoretically attractive, these findings suggest the routine use of ANH is unlikely to be beneficial.  

This large retrospective target trial emulation examined whether initiation of GLP-1 receptor agonists (GLP-1RAs) was associated with an increased risk of thyroid cancer in adults with type 2 diabetes at moderate cardiovascular risk. While the overall absolute risk of thyroid cancer was low, there was a transient increase in risk during the first year of GLP-1RA use.

Summary: GLP-1RAs are exponentially increasing in use, particularly in recent years, raising concerns about a potential link to thyroid cancer—especially medullary and, more recently, papillary types. This prespecified secondary analysis of a target trial emulation compared GLP-1RA, SGLT2i, DPP4i, and sulfonylureas in adults with type 2 diabetes at moderate cardiovascular risk, using a counterfactual framework and administrative claims data from a nationally representative U.S. population. Adults aged ≥21 with 1–5% annual predicted cardiovascular risk who newly initiated one of these treatments between 2014 and 2021 were included, with exclusions for prior use of study drugs, insulin, pregnancy, thyroid cancer, or type 1 diabetes.

The primary outcome was incident thyroid cancer based on ICD codes, with two emulated trials comparing GLP-1RA against other drug classes. Primary analyses used a modified intention-to-treat (mITT) approach and incorporated inverse probability weights into cause-specific Cox models to estimate hazard ratios and cumulative incidence. Among 351,913 eligible patients, thyroid cancer diagnoses were rare, with similar incidence across groups (e.g., 0.17% in GLP-1RA and SGLT2i users, 0.20% in SU, and 0.23% in DPP4i users). The overall mITT analysis showed no significant increased risk in GLP-1RA users (HR 1.24; 95% CI, 0.88–1.76), though a higher risk was observed within the first year (HR 1.85; 95% CI, 1.11–3.08), and in sensitivity analyses including the as-treated approach (HR 2.07; 95% CI, 1.10–3.95). GLP-1RA initiators had a significantly higher likelihood of undergoing thyroid ultrasonography (log rank P<.01), especially within the first 6 to 12 months of initiation.

Higher thyroid ultrasonography rates among GLP-1RA users point to a likely detection bias driving early cancer diagnoses. Although the as-treated analysis may better reflect active exposure, it is still vulnerable to unmeasured confounding and immortal time bias. The use of administrative claims data also limits access to clinical detail, including tumor subtype, size, and severity, and the study could not account for genetic or familial risk factors.

Bottom Line: GLP-1RA use was not associated with a sustained increased risk of thyroid cancer. 

This is a 6-month pilot study of general surgery faculty and residents at McMaster University (Canada) evaluating the impact of a Surgical Education Checklist (SEC) as a perioperative tool to facilitate learning discussions and completion of Entrustable Professional Activity (EPA) assessments. Authors found that SEC implementation was associated with quantitative improvement in the number of triggered EPA assessments, but a decline in the overall proportion of completed assessments, with no qualitative improvement in experience or engagement with the competency-based framework. Future work is needed to optimize the SEC and develop additional strategies to increase EPA completion so that these assessments can be meaningful educational tools for competency-based surgical training. 

Summary: There is a worldwide focus on shifting to competency and outcomes-based surgical training. As part of this effort, the Royal College of Physician and Surgeons of Canada implemented the Competency by Design (CBD) framework, which divides the surgical residency curriculum into four distinct stages of training, each with a set of required Entrustable Professional Activities (EPAs). However, completing EPA requirements has proven quite challenging. Therefore, faculty and residents in the Division of General Surgery at McMaster University designed the Surgical Education Checklist (SEC), a printed checklist placed inside and outside of the OR that lists preoperative and postoperative discussion items to promote discussion of case-specific goals and EPA opportunities, as well as a QR code linked to the digital EPA portal system. 

A pilot study of the SEC was performed January-June 2023 at 5 McMaster University-affiliated teaching hospitals. All general surgery residents and faculty in the Division of General Surgery were eligible for inclusion. Data was collected using pre- and post-intervention mixed methods online surveys and the digital EPA portal system. The primary outcome was the proportion of completed EPA assessments in the pre- (July 1 – December 31, 2022) and post-intervention (January 1 – June 30, 2023) periods. Secondary outcomes included qualitative experience with CBD: resident and faculty understanding of CBD framework and satisfaction with its implementation, perceived usefulness of EPA assessments, and user experience with SEC. Descriptive statistics and univariate analyses were performed for pre- and post-checklist quantitative outcomes. Thematic analysis was used for survey free-text responses. 

Surveys were distributed to 71 eligible residents and faculty. The overall response rate was 34 (47.9%) and 11 (15.5%) for pre- and post-checklist surveys, respectively. After implementation of the SEC, no significant changes were observed in number of self-reported EPA assessments by residents (2.2 ± 0.7 vs 2.5 ± 0.7, p = 0.32) or faculty (3.3 ± 1.4 vs 4 ± 0, p = 0.41). The overall number of triggered EPAs increased from 485 to 639, but the proportion of completed EPAs prior to expiration decreased (82.5% vs 74.6%, p < 0.01) and there was no significant change in the overall proportion of EPAs completed. Mean number of EPA assessments completed by general surgery faculty did not change significantly (8.5 ± 7.7 vs 10.1 ± 7.5, p = 0.31). In subgroup analysis by post-graduate (PGY) level, significantly more EPAs were triggered by PGY 1-3 residents after SEC implementation, with no differences among PGY4 residents, and fewer triggered EPAs among PGY5 residents. In qualitative analysis no significant changes were observed in the understanding, use, or satisfaction with CBD educational framework. Residents did express reduced anxiety around EPA assessments (4.2 ± 0.6 vs 3.3 ± 1.1, p = 0.01) and increased sentiment of EPA keeping them on track to graduate as competent surgeons (2.6 ± 0.7 vs 4 ± 0, p < 0.01). Both residents and faculty agreed that the SEC was accessible, but expressed poor adherence due to barriers such as staff availability, time constraints, lack of awareness and buy-in. 

Limitations of this study include the low response rate, which may have introduced selection bias and limited the statistical power to detect pre- and post-intervention differences. Additionally, the short implementation window and poor adherence to the SEC may have limited the ability to fully assess the impact of the SEC on CBD adoption and EPA completion. Seeing as this was a pilot study, it identified important gaps that may have impacted user experience and adherence. Authors have since developed SEC 2.0, which is being implemented and studied over a full academic year. 

Bottom Line: In this proof-of-concept study, implementation of a Surgical Education Checklist (SEC) increased the number of triggered EPA assessments, particularly among junior residents, but decreased the proportion of completed assessments, and did not subjectively enhance the resident or faculty educational experience or engagement with the competency-based framework.