Increasing Pancreatic Cancer Incidence in Young Women in the United States: A Population-Based Time-Trend Analysis, 2001-2018.

BACKGROUND & AIMS: Previous studies have shown an increasing incidence of pancreatic cancer (PC), especially in younger women; however, this has not been externally validated. In addition, there are limited data about contributing factors to this trend. We report age and sex-specific time-trend analysis of PC age-adjusted incidence rates (aIRs) using the National Program of Cancer Registries database without Surveillance Epidemiology and End Results data. METHODS: PC aIR, mortality rates, annual percentage change, and average annual percentage change (AAPC) were calculated and assessed for parallelism and identicalness. Age-specific analyses were conducted in older (≥55 years) and younger (<55 years) adults. PC incidence based on demographics, tumor characteristics, and mortality were evaluated in younger adults. RESULTS: A total of 454,611 patients were diagnosed with PC between 2001 and 2018 with significantly increasing aIR in women (AAPC = 1.27%) and men (AAPC = 1.14%) without a difference (P = .37). Similar results were seen in older adults. However, in younger adults (53,051 cases; 42.9% women), women experienced a greater increase in aIR than men (AAPCs = 2.36%, P < .001 vs 0.62%, P = 0.62) with nonparallel trends (P < .001) and AAPC difference of 1.74% (P < .001). This AAPC difference appears to be due to rising aIR in Blacks (2.23%; P < .001), adenocarcinoma histopathologic subtype (0.89%; P = .003), and location in the head-of-pancreas (1.64%; P < .001). PC mortality was found to be unchanged in women but decreasing in counterpart men (AAPC difference = 0.54%; P = .001). CONCLUSION: Using nationwide data, covering ≈64.5% of the U.S. population, we externally validate a rapidly increasing aIR of PC in younger women. There was a big separation of the incidence trend between women and men aged 15-34 years between 2001 and 2018 (>200% difference), and it did not show slowing down.

Epidemiologic risk factors for patients admitted with chronic pancreatitis and pancreatic ductal adenocarcinoma in the United States.

BACKGROUND: Epidemiological studies of chronic pancreatitis (CP) and its association with pancreatic ductal adenocarcinoma (PDAC) are limited. Understanding demographic and ethno-racial factors may help identify patients at the highest risk for CP and PDAC. AIM: To evaluate the ethno-racial risk factors for CP and its association with PDAC. The secondary aim was to evaluate hospitalization outcomes in patients admitted with CP and PDAC. METHODS: This retrospective cohort study used the 2016 and 2017 National Inpatient Sample databases. Patients included in the study had ICD-10 codes for CP and PDAC. The ethnic, socioeconomic, and racial backgrounds of patients with CP and PDAC were analyzed. RESULTS: Hospital admissions for CP was 29 per 100000, and 2890 (0.78%) had PDAC. Blacks [adjusted odds ratio (aOR) 1.13], men (aOR 1.35), age 40 to 59 (aOR 2.60), and being overweight (aOR 1.34) were significantly associated with CP (all with P < 0.01). In patients with CP, Whites (aOR 1.23), higher income, older age (aOR 1.05), and being overweight (aOR 2.40) were all significantly associated with PDAC (all with P < 0.01). Men (aOR 1.81) and Asians (aOR 15.19) had significantly increased mortality (P < 0.05). Hispanics had significantly increased hospital length of stay (aOR 5.24) (P < 0.05). CONCLUSION: Based on this large, nationwide analysis, black men between 40-59 years old and overweight are at significantly increased risk for admission with CP. White men older than 40 years old and overweight with higher income were found to have significant associations with CP and PDAC. This discrepancy may reflect underlying differences in healthcare access and utilization among different socioeconomic and ethno-racial groups.

Comparison of no stent fixation, endoscopic suturing, and a novel over-the-scope clip for stent fixation in preventing migration of fully covered self-expanding metal stents: a retrospective comparative study (with video).

BACKGROUND AND AIMS: Endoscopic suturing and over-the-scope clips (OTSCs) are used to prevent migration of fully covered self-expandable metal stents (FCSEMSs). Recently, a dedicated OTSC was developed for securing FCSEMSs. Our primary aim was to compare the frequency of stent migration without stent fixation versus fixation with suturing or OTSCs, and out secondary aims were to compare clinical success, procedure duration, and adverse events. METHODS: A retrospective cohort study evaluated the outcome of stent placement throughout the entire GI tract from 2013 to 2021. Stent migration was determined as stent displacement ≥2 cm endoscopically or radiographically. Clinical success was defined as resolution of indication at follow-up. RESULTS: Four hundred thirty-three procedures were performed, 239 (55%) without fixation, 140 (32%) with suturing, and 54 (12%) with OTSCs. Stent migration rates were 62% without fixation, 57% with suturing, and 35% with OTSCs (P = .013). The median time to stent migration was 3 weeks without fixation, 5 weeks with suturing, and 6 weeks with OTSCs (P = .023). The clinical success rate was 43%. The median procedure time for OTSCs was shorter compared with suturing (42 vs 68 minutes, P = .002). Adverse event rates trended toward being lowest with OTSCs at 9% compared with 21% without fixation and 18% with suturing (P > .05). CONCLUSIONS: OTSCs for stent fixation were found to have significantly lower migration rates compared with no fixation and suturing. Moreover, OTSCs were associated with decreased overall procedure time and total costs per procedure while trending to be associated with fewer adverse events.

Novel Endoscopic Polypectomy Surveillance Technique for Fundic Gland Polyps in Familial Adenomatous Polyposis Can Improve Early Detection of Dysplasia and Gastric Cancer.

INTRODUCTION: Fundic gland polyps (FGPs) are commonly found in patients with familial adenomatous polyposis (FAP) and are considered benign. Biopsies are not routinely performed, and conventional forceps may be time-consuming and/or yield nonrepresentative histology. The purpose of this study was to evaluate the role of a novel endoscopic polypectomy surveillance (EPS), a large volume cold-snare polypectomy technique of random FGPs, in the incidence of dysplasia and gastric cancer (GC) in FAP. METHODS: This is a retrospective longitudinal cohort of patients with FAP referred to a tertiary care center for duodenal adenoma surveillance and who underwent EPS of FGPs between 2001 and 2019. Demographic, endoscopic, and clinicopathologic information was reviewed. RESULTS: Thirty-five patients with FAP were identified at initial endoscopy by the mean age of 43.4 years (±12.8). One hundred thirteen surveillance endoscopies were performed in total using EPS. Dysplasia of FGPs was present on initial esophagogastroduodenoscopy in 7 patients (20%), and 13 additional patients (46.4%) progressed to low-grade dysplasia. Three patients (15%) who subsequently had progression to GC were found to have signet ring cell cancer within the foci of FGPs through EPS. One patient presented as metastatic GC. Progression from nondysplastic FGP to low-grade dysplasia occurred over 63 months (±46.3) with further progression to GC over 34 months (±8.5). Endoscopic risk factors for cancer were polyps >10 mm in size ( P < 0.001) and carpeting of polyps ( P < 0.001). The 5-year cumulative incidence of developing dysplasia was 35.7%. DISCUSSION: We identified that the incidence of dysplasia and GC is higher than previously reported in patients with FAP. Our study used a novel EPS technique and was able to identify GC within the foci of FGPs. Upper endoscopic guidelines should include a more rigorous sampling method for FGPs, such as EPS, to optimize early detection of dysplasia and GC.

Polypectomy for Large Polyps with Endoscopic Mucosal Resection.

Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience.

BACKGROUND: Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis. METHODS: This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence. RESULTS: 66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %). CONCLUSIONS: The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.

Feasibility and safety study of 22-gauge endoscopic ultrasound (EUS) needles for portal vein sampling in a swine model.

Background and study aims Endoscopic ultrasound (EUS) has been used for portal vein sampling in patients with pancreaticobiliary cancers for enumerating circulating tumor cells but is not yet a standard procedure. Further evaluation is needed to refine the methodology. Therefore, we evaluated the feasibility and safety of 19-gauge (19G) versus a 22-gauge (22 G) EUS fine-needle aspiration needles for portal vein sampling in a swine model. Methods Celiotomy was performed on two farm pigs. Portal vein sampling occurred transhepatically. We compared 19 G and 22 G needles coated interiorly with saline, heparin or ethylenediaminetetraacetic acid (EDTA). Small- (10 mL) and large- (25 mL) volume blood collections were evaluated. Two different collection methods were tested: direct-to-vial and suction syringe. A bleeding risk trial for saline-coated 19 G and 22 G needles was performed by puncturing the portal vein 20 times. Persistent bleeding after 3 minutes was considered significant. Results All small-volume collection trials were successful except for 22 G saline-coated needles with direct-to-vial method. All large-volume collection trials were successful when using suction syringe; direct-to-vial method for both 19 G and 22 G needles were unsuccessful. Collection times were shorter for 19 G vs. 22 G needles for both small and large-volume collections ( P  < 0.05). Collection times for saline-coated 22 G needles were longer compared to heparin/EDTA-coated ( P  < 0.05). Bleeding occurred in 10 % punctures with 19 G needles compared to 0 % with 22 G needles. Conclusion The results of this animal study demonstrate the feasibility and the safety of using 22 G needles for portal vein sampling and can form the basis for a pilot study in patients.

Normalidad post-pandemia: ¿una nueva normalidad socio-ambiental o adiós a la normalidad? / Post-pandemic normality: a new normal socio-environmental or goodbye to normality?

Instalada la pandemia de la Covid-19 la gran expectativa colectiva gira en torno al retorno a la normalidad. En este ensayo se pone en entredicho el concepto de 'normalidad' en el contexto de los factores determinantes de la emergencia de los virus con altas tasas de morbilidad y mortalidad, evidenciando que el estado de 'normalidad pre-pandemia', al cual se aspira retornar, presenta indicadores socio-ambientales mucho más preocupantes y trágicos que aquellos que la mediática global nos suministra, de manera permanente y en tiempo real, sobre la Covid-19. Se presentan evidencias para argumentar que el principio sine qua non del crecimiento económico como motor determinante e insustituible del desarrollo, y más aún del modelo capitalista de desarrollo, es metabólicamente insostenible al demandar cantidades permanentemente incrementales de energía y bienes de la naturaleza en un planeta incapaz de sostener semejante pretensión. Las pandemias no son las únicas consecuencias fatales de la destrucción de la naturaleza y tampoco las más graves. Son síntomas de un modelo en crisis, que el desarrollo sustentable pretende aliviar sin avocarse al tratamiento de la patología que los origina. Por este motivo, se sostiene que es necesario construir una 'nueva normalidad', diferente a la 'normalidad pre-pandemia' por ser esta inviable, lo que implica evaluar los fundamentos del modelo. Se convoca a una impostergable reflexión, diversa e inclusiva, desde el seno de la comunidad científica, con el desprendimiento suficiente para admitir otras visiones y conocimientos que tienen mucho que aportar desde otras formas de coexistir con la naturaleza(AU)

Once Covid-19 pandemic established among us, the great collective expectation is about the return to normal pre-pandemic conditions. This assay questions the concept of 'normality' related to the context where high morbidity-mortality virus emerge out, showing that pre-pandemic normal conditions, have worst and overwhelming socio-environmental indicators than Covid-19 reports, daily supplied by global mass media in real time. We offer evidences that suggest that the sine qua non principle of economic growth, as indisputable driver of development, and even more, of the capitalist model, is metabolically unsustainable, due to the astonishing demands of energy and goods from nature, beyond its own capacity. Pandemics are not the only fatal consequences of ecological destruction, and by no means among the worst. They are just a symptom of the crisis of the development model, which the sustainable development pretends to relieve, ignoring the pathology that originated it. Due to this fact, we sustain that a new normal conditions is required to be created, truly different to pre-pandemic conditions, and that demands assessing the model's principles. We invite the scientific society for an urgent, inclusive and diverse reflection, willing to recognize other perspectives and knowledge, that could offer alternatives ways to coexist with nature(AU)

Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps.

Background and study aims Standard endoscopic mucosal resection (EMR) of ileocecal valve (ICV) polyps is challenging. Cap-assisted endoscopic mucosal resection (C-EMR) can be performed when polyps are not easily amenable to standard EMR. Current literature is limited regarding its efficacy and safety for ICV polyps. The objectives of this study were to assess the efficacy and safety of C-EMR for ICV polyps. Patients and methods A retrospective review was conducted from September 2008 to November 2018 at a tertiary care center. Patients included in the study underwent C-EMR for ICV polyps by a single gastroenterologist (LHJ). Polyps were successfully eradicated if they were removed en-bloc as confirmed by pathology, or had a negative biopsy on follow-up colonoscopy. Outcomes of the procedures were evaluated, including complete adenoma clearance and adverse events. Results Twenty-one ICV polyps were removed with C-EMR. Median polyp size was 15 mm (range, 5-45). The rate of complete adenoma clearance was 100 %. Procedure-related complications occurred in five patients (24 %): delayed GI bleeding (4.8 %) and deep mucosal resection/visible vessel (14.3 %). Three patients had subsequent surveillance colonoscopies at 8, 56, and 67 months, respectively. The third patient was found to have a 6-mm flat polyp at the edge of the previous polypectomy site. This was treated with C-EMR and repeat colonoscopy 6 months later did not show residual. Conclusion C-EMR is highly effective in treating ICV polyps with a low complication rate. It is our suggested method in approaching ICV polyps that are difficult to remove via standard freehand snare EMR technique.

The Benefice of Mobile Parts' Exchange in the Management of Infected Total Joint Arthroplasties with Prosthesis Retention (DAIR Procedure).

Background: The management of prosthetic joint infections (PJI) with debridement and retention of the implant (DAIR) has its rules. Some authors claim that lacking the exchange of mobile prosthetic parts is doomed to failure, while others regard it as optional. Methods: Single-center retrospective cohort in PJIs treated with DAIR. Results: We included 112 PJIs (69 total hip arthroplasties, 9 medullary hip prostheses, 41 total knee arthroplasties, and 1 total shoulder arthroplasty) in 112 patients (median age 75 years, 52 females (46%), 31 (28%) immune-suppressed) and performed a DAIR procedure in all cases-48 (43%) with exchange of mobile parts and 64 without. After a median follow-up of 3.3 years, 94 patients (84%) remained in remission. In multivariate Cox regression analysis, remission was unrelated to PJI localization, pathogens, number of surgical lavages, duration of total antibiotic treatment or intravenous therapy, choice of antibiotic agents, immune-suppression, or age. In contrast, the exchange of mobile parts was protective (hazard ratio 1.9; 95% confidence interval 1.2⁻2.9). Conclusions: In our retrospective single-center cohort, changing mobile parts of PJI during the DAIR approach almost doubled the probability for long-term remission.

Comparing the Real-World Effectiveness of Competing Colonoscopy Preparations: Results of a Prospective Trial.

OBJECTIVES: National societies provide little guidance regarding which colonoscopy bowel preps are best tolerated and most effective; this reflects a lack of comparative effectiveness studies that directly evaluate the available preps in a "real-world" setting. To address this gap, we conducted a prospective, commercially unfunded comparative effectiveness study of currently available bowel preps and measured their impact on bowel cleansing. METHODS: We included patients aged ≥18 years, who presented for an outpatient colonoscopy at a large medical center serving more than 70 academic and community-based endoscopists who are free to prescribe the bowel prep of their choice. The primary outcome was bowel cleansing quality as measured by the Boston Bowel Preparation Scale. We performed regression models with random effects on the outcomes to adjust for confounding. RESULTS: Approximately 4,339 colonoscopies were performed by 75 endoscopists. Magnesium citrate, MiraLAX with Gatorade, MoviPrep, OsmoPrep, Prepopik/Clenpiq, and Suprep all had significantly higher prep tolerability compared with GoLYTELY (all P < 0.05). For bowel cleansing, Suprep (7.28 ± 1.66; P < 0.001), MoviPrep (7.11 ± 1.62; P = 0.004), and MiraLAX with Gatorade (7.09 ± 1.64; P < 0.001) had higher total Boston Bowel Preparation Scale scores compared with GoLYTELY (6.67 ± 1.87); there were no significant differences among the remaining preps. Split-prep dosing was associated with better cleansing; however, men, opioid and tricyclic antidepressent users, and patients with diabetes and cirrhosis had worse cleansing (all P < 0.05). CONCLUSIONS: In this prospective, real-world comparative effectiveness study of available bowel preps, we found that MiraLAX with Gatorade, MoviPrep, and Suprep were prospectively associated with superior tolerability and bowel cleansing.

Genetic associations with adverse events from anti-tumor necrosis factor therapy in inflammatory bowel disease patients.

AIM: To study the type and frequency of adverse events associated with anti-tumor necrosis factor (TNF) therapy and evaluate for any serologic and genetic associations. METHODS: This study was a retrospective review of patients attending the inflammatory bowel disease (IBD) centers at Cedars-Sinai IBD Center from 2005-2016. Adverse events were identified via chart review. IBD serologies were measured by ELISA. DNA samples were genotyped at Cedars-Sinai using Illumina Infinium Immunochipv1 array per manufacturer's protocol. SNPs underwent methodological review and were evaluated using several SNP statistic parameters to ensure optimal allele-calling. Standard and rigorous QC criteria were applied to the genetic data, which was generated using immunochip. Genetic association was assessed by logistic regression after correcting for population structure. RESULTS: Altogether we identified 1258 IBD subjects exposed to anti-TNF agents in whom Immunochip data were available. 269/1258 patients (21%) were found to have adverse events to an anti-TNF-α agent that required the therapy to be discontinued. 25% of women compared to 17% of men experienced an adverse event. All adverse events resolved after discontinuing the anti-TNF agent. In total: n = 66 (5%) infusion reactions; n = 49 (4%) allergic/serum sickness reactions; n = 19 (1.5%) lupus-like reactions, n = 52 (4%) rash, n = 18 (1.4%) infections. In Crohn's disease, IgA ASCA (P = 0.04) and IgG-ASCA (P = 0.02) levels were also lower in patients with any adverse events, and anti-I2 level in ulcerative colitis was significantly associated with infusion reactions (P = 0.008). The logistic regression/human annotation and network analyses performed on the Immunochip data implicated the following five signaling pathways: JAK-STAT (Janus Kinase-signal transducer and activator of transcription), measles, IBD, cytokine-cytokine receptor interaction, and toxoplasmosis for any adverse event. CONCLUSION: Our study shows 1 in 5 IBD patients experience an adverse event to anti-TNF therapy with novel serologic, genetic , and pathways associations.

Resolution of Diffuse Intrahepatic Biliary Strictures after Chemotherapy for Metastatic Ovarian Cancer.

Sclerosing cholangitis and cholestatic jaundice secondary to metastatic disease is a rare complication. We report a rare case of secondary sclerosing cholangitis (SSC) due to lymphatic spread from ovarian cancer with complete resolution after chemotherapy. The diagnosis of SSC from metastatic ovarian cancer was clinically challenging, as endoscopic retrograde cholangiopancreatography revealed irregular hepatic ducts consistent with sclerosing cholangitis, but it did not identify any malignant cells. The final diagnosis was made with liver biopsy revealing high-grade metastatic Mullerian carcinoma. The patient responded well to chemotherapy and is in remission. A timely diagnosis is important and can lead to complete resolution of the disease.

Chronic Pancreatitis: Current Status and Challenges for Prevention and Treatment.

This paper reviews the current status of our understanding of the epidemiology, diagnosis, and management of the continuum of pancreatic diseases from acute and recurrent acute pancreatitis to chronic pancreatitis and the diseases that are often linked with pancreatitis including diabetes mellitus and pancreatic cancer. In addition to reviewing the current state of the field, we identify gaps in knowledge that are necessary to address to improve patient outcomes in these conditions.

Diabetic foot infections: what have we learned in the last 30 years?

BACKGROUND: Infection is a common epiphenomenon of advanced diabetic foot disease and the most common reason for diabetes-related hospitalizations and lower extremity amputations. Major advances have been made in the past three decades in our understanding and management of diabetic foot infections (DFIs). The optimal treatment of DFIs clearly involves multidisciplinary input. METHODS: A comprehensive search of the literature on DFIs from January 1960 through June 2015 was performed, with an emphasis on information published in the past 30 years. RESULTS: There have been many new insights into the microbiology, diagnosis, and treatment of DFIs, although the implementation of this knowledge in clinical practice has been suboptimal. Today, the use of evidence-based guidelines, multidisciplinary teams, and institution-specific clinical pathways helps guide optimal care of this multifaceted problem. Patients are more often treated in the ambulatory setting, with antibiotic regimens that are more targeted, oral and shorter course, and with more conservative (but earlier) surgical interventions. New diagnostic and therapeutic methods are being developed at an accelerating pace. CONCLUSIONS: The worldwide increase in the incidence of diabetes and longer lifespan of diabetic patients will undoubtedly increase the incidence of DFIs. Clinicians caring for diabetic patients should have an understanding of current methods for preventing, diagnosing, and treating DFIs.

Upper esophageal and pharyngeal cancers.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on laryngopharyngeal reflux as a risk factor for laryngeal cancer; the role of pepsin in laryngopharyngeal neoplasia; natural fruit and vegetable compounds for the prevention and treatment of pharyngeal and esophageal cancers; and evaluation of cranberry constituents as inhibitors of esophageal adenocarcinoma utilizing in vitro assay and in vivo models.

Treatment challenges associated with bone echinococcosis.

OBJECTIVES: In this literature review, we concentrate on epidemiology and therapy of osseous echinococcosis, with an emphasis on the recurrence risk. METHODS: Literature review 1930-2012. RESULTS: We retrieved 200 publications based upon single case reports or case series, mostly from resource-poor settings. Among the 721 rural patients (22% females; median age 37 years), 60% of all reported cases were from the Mediterranean region and almost all patients were immune competent. Echinococcus granulosus was identified as the most frequent species. Most infections involved a single bone (602/721; 83%) and often the spine (321 cases; 45%). In eight cases (8/702; 1%), a secondary bacterial surgical site infection was reported. Surgical intervention was performed in 702 cases (97%), with single intervention in 687 episodes (95%). Complete excision of the lesion was possible in only 117 episodes (16%). Albendazole was by far the most frequently used agent in monotherapy with various dosages, while mebendazole in monotherapy was less frequent (32 cases). The median duration of antihelminthic therapy was 6 months (range 0.7-144 months). There were 124 recurrences (17%) after a median delay of 2 years (range 0.4-17 years). In multivariate analysis, the presence of visceral organ involvement increased the odds of recurrence by 5.4 (95% CI 3.1-9.4), whereas the number of surgical interventions, the duration of antihelminthic therapy or the use of hypertonic saline did not influence recurrence. CONCLUSIONS: Bone echinococcosis is a rare parasitic disease. While treatment modalities vary considerably, combined surgical and medical approaches are the standard of care with a 17% risk of recurrence.

Chronic osteomyelitis.

Chronic osteomyelitis is a multifaceted bacterial infection with common features. It absolutely requires surgery for remission. The duration and form of concomitant administration of antibiotic agents for adult patients is still based on expert opinion. The traditional recommendation of 6-12 weeks of antibiotic therapy, where, for at least the first 2-6 weeks, antibiotics should be administered intravenously, is more and more challenged in favor of an oral antibiotic treatment with selected agents from the start. There is no evidence that the total duration of antibiotic therapy for more than 4-6 weeks improves outcome, when compared with shorter regimens. Hopefully, the future will show randomized trials in the adult population, allowing optimal timing of surgical and medical therapy and sparing of unnecessary prescription, with concomitant development of antibiotic resistance. External advice from an expert team with combined surgeons and infectious disease physicians may help to reduce antibiotic consumption in a cost-effective way.