Isolated Comminuted Fracture Of The Cricoid Cartilage and Narrowing Of The Airway After A Traumatic Blunt Injury Of The Neck
This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma.
KEY FINDINGS: This case report highlights the conservative treatment of isolated cricoid cartilage fracture in the setting of low-energy blunt trauma. The patient was clinically stable and treated conservatively with oxygen therapy and silence therapy (complete silence).
BACKGROUND: Blunt trauma to the anterior of the neck may compromise the vital structures like major blood vessels, trachea, larynx, pharynx, thyroid, spine, esophagus, and the cricoid. Laryngeal trauma is rare and accounts for 1% of all neck blunt traumas. Cricoid trauma is also very rare and accounts for half of the laryngeal traumas, and the diagnosis is frequently missed.
DETAILS: A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook, was referred to the Shahid Beheshti Hospital. The patient complained of dysphonia (hoarseness) and dyspnea. The CT scans showed a comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord.
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Source: Mehrabi, S., Hosseinpour, R., and Barhaghtalab, M. J. (2022). Isolated Comminuted Fracture Of The Cricoid Cartilage and Narrowing Of The Airway After A Traumatic Blunt Injury Of The Neck: A Case Report. Int J Emerg Med. 2022; 15:55. Published: November, 2022. DOI: 10.1186/s12245-022-00459-9.
Enhanced Recovery Protocols May Improve Outcomes After Pediatric Gastrointestinal Surgery When Adherence Is High
In the ENRICH-US trial of 597 children and adolescents undergoing gastrointestinal surgery, implementing an enhanced recovery protocol did not significantly reduce overall hospital length of stay. However, patients who received at least 13 protocol elements had stays that were 1.14 days shorter and lower odds of postoperative complications. The findings underscore the importance of consistent protocol adherence when translating enhanced recovery strategies into better surgical outcomes.
KEY FINDINGS: The ENRICH-US trial did not demonstrate a significant overall reduction in length of stay from introducing a multifaceted implementation strategy. However, patients receiving a greater number of protocol elements experienced shorter hospital stays and fewer complications. These findings emphasize that the clinical benefit of enhanced recovery pathways may depend on consistent delivery of their components, not simply on adopting a protocol. Hospitals implementing pediatric ERPs should therefore monitor adherence alongside clinical outcomes and address organizational barriers that limit reliable implementation.
BACKGROUND: Enhanced recovery protocols (ERPs) combine evidence-based perioperative practices to support recovery, reduce opioid exposure, and minimize complications after surgery. Although these protocols are well established in adult surgical care, their implementation in pediatric populations has been slower. The ENRICH-US trial evaluated whether a structured implementation strategy could improve adherence to a pediatric gastrointestinal surgery ERP and enhance clinical outcomes.
DETAILS: This prospective, stepped-wedge cluster-randomized implementation-effectiveness trial included 597 patients aged 10-18 years undergoing elective gastrointestinal surgery at 18 US sites between September 2019 and June 2024. The protocol included 21 perioperative elements, supported by a structured implementation toolkit, multidisciplinary learning sessions, adherence feedback, and implementation reports. Outcomes were assessed during baseline usual care, implementation, and sustainability phases. The primary clinical outcome was postoperative hospital length of stay (LOS). Secondary outcomes included time to resumption of a regular diet, inpatient opioid use, postoperative complications, opioid prescriptions at discharge, 30-day readmission, and patient-reported health-related quality of life.
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Inflammatory bowel disease was the most common surgical indication, accounting for 433 patients (72.5%). Across the three study phases, the implementation strategy did not significantly reduce overall hospital LOS or produce significant differences in most secondary outcomes. However, patients resumed a regular diet sooner and had lower opioid use during hospitalization as the protocol progressed. A patient-level analysis demonstrated the importance of adherence. Patients who received at least 13 ERP elements had a median hospital stay that was 1.14 days shorter (95% CI, -2.01 to -0.27) and lower odds of postoperative complications (adjusted odds ratio, 0.48; 95% CI, 0.28-0.82) than patients with lower adherence. The median number of protocol elements delivered increased from 11 during baseline to 14 during both implementation and sustainability phases (P < .001).
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Source: Raval, M. V., Tian, Y., Schäfer, W., et al. Implementation and Effectiveness of an Enhanced Recovery Protocol for Children Undergoing Surgery: The ENRICH-US Stepped-Wedge Cluster-Randomized Trial. JAMA Surgery. 2026; 161(7): 670-680. Published: October, 2026. DOI: 10.1001/jamasurg.2026.1382.
Frailty and Hospitalization Risk in Older Adults Presenting to the Emergency Department
A Japanese study of 3,127 emergency department visits among adults aged 65 years or older found that frailty was associated with higher odds of hospitalization in patients assigned moderate- and lower-acuity triage categories. The overall interaction between frailty and triage urgency was not statistically significant, underscoring the need for further research into how frailty can support geriatric emergency assessment and disposition decisions.
KEY FINDINGS: This study suggests that frailty may provide clinically relevant information when assessing hospitalization needs in older adults presenting to the emergency department. The association was most apparent in patients assigned lower triage urgency categories, although the formal analysis did not confirm a statistically significant difference across categories.
Incorporating frailty assessment into geriatric emergency care may help clinicians consider functional vulnerability alongside acute illness severity. However, the findings are based on a single-center retrospective study and do not establish that frailty itself causes hospitalization. Further prospective, multicenter research is needed to clarify how frailty, social circumstances, clinical decision-making, and healthcare-system factors influence disposition.
BACKGROUND: Emergency department (ED) triage systems prioritize patients according to the urgency of their acute medical conditions. However, among older adults, frailty may also influence the need for hospitalization, even when patients have similar triage-assessed urgency. Understanding the relationship between frailty and hospital admission may help clinicians improve geriatric assessment and disposition decisions in emergency care.
DETAILS: This single-center retrospective cohort study was conducted at an urban tertiary hospital in Japan. Investigators analyzed emergency department visits by patients aged 65 years or older between November 2025 and March 2026. Frailty was defined as a score of 5 or higher on the Clinical Frailty Scale (CFS). Triage urgency was classified using the Japan Triage and Acuity Scale (JTAS). The primary outcome was hospitalization at the study hospital or transfer to another acute-care hospital. The investigators used mixed-effects logistic regression, adjusting for age, sex, mode of arrival, injury- or poisoning-related visits, living arrangements, and long-term care needs certification. The analysis also examined whether the association between frailty and hospitalization differed across triage categories.
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The study included 3,127 emergency department visits, of which 1,526 resulted in hospitalization. Among patients in JTAS category 2, frailty was not significantly associated with hospitalization (adjusted odds ratio [OR], 1.00; 95% CI, 0.65–1.55). In category 3, frailty was associated with higher odds of hospitalization (OR, 1.54; 95% CI, 1.19–1.99). In the combined JTAS categories 4 and 5, the adjusted odds of hospitalization were approximately twice as high among frail patients (OR, 2.01; 95% CI, 1.13–3.58). The association between frailty and hospitalization appeared stronger in the lower-acuity categories. However, the overall interaction between frailty and triage category was not statistically significant (P = 0.091), so the study did not establish that the association differed across triage levels.
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Source: Hata, N., Nagae, M., and Umegaki, H. Frailty and Hospitalization After Emergency Department Evaluation Within Triage Categories in Older Patients: A Retrospective Cohort Study. Academic Emergency Medicine. 2026; 33(10). Published: August 22, 2026. DOI: 10.1111/acem.70419.
Body Composition Abnormalities in Heart Failure May Be Underestimated by BMI
A UK Biobank imaging study found that patients with heart failure had greater visceral fat, lower muscle volume, and more muscle fat infiltration than age-, sex-, and BMI-matched controls. Body composition patterns varied across heart failure phenotypes, while sarcopenia prevalence differed substantially depending on the diagnostic criteria used. The findings highlight the limitations of BMI alone in assessing metabolic and muscular abnormalities in heart failure.
KEY FINDINGS: This study found that HF was associated with increased visceral adiposity, reduced muscle volume, and greater muscle fat infiltration, even when patients were compared with controls matched for BMI. The differing patterns across HF phenotypes suggest that body composition abnormalities are not uniform among patients with heart failure.
The findings indicate that BMI and conventional anthropometric measures may underestimate clinically relevant metabolic and muscular abnormalities. Advanced imaging and more consistent definitions of sarcopenia may improve characterization of these abnormalities, although further research is needed to determine their prognostic value and implications for treatment.
BACKGROUND: Heart failure (HF) is associated with metabolic and musculoskeletal abnormalities that may not be adequately captured by body mass index (BMI). Excess visceral fat, reduced skeletal muscle volume, and increased fat infiltration within muscle can coexist and may differ across HF phenotypes. This study used advanced imaging to characterize body composition in patients with HF compared with matched controls and to examine differences among HF with reduced ejection fraction (HFrEF), mildly reduced ejection fraction (HFmrEF), and preserved ejection fraction (HFpEF).
DETAILS: Researchers analyzed participants in the UK Biobank Imaging Study. A total of 185 individuals with HF and available ejection fraction measurements were matched in a 1:5 ratio with 925 controls matched for age, sex, and BMI. Whole-body magnetic resonance imaging (MRI) was used to quantify visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue, liver fat, thigh fat-free muscle volume, and muscle fat infiltration (MFI). Dual-energy x-ray absorptiometry (DXA) was used to measure total fat and appendicular lean mass. Personalized z-scores adjusted for sex and body size were calculated. Adverse muscle composition (AMC) was defined by the combination of low muscle volume and high muscle fat infiltration. The investigators also assessed sarcopenia using grip strength and DXA-derived lean mass criteria.
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Compared with matched controls, participants with HF had significantly greater visceral adipose tissue (z-score, 0.46 ± 1.1 vs 0.07 ± 1.0; P < 0.001) and muscle fat infiltration (8.4% ± 2.3% vs 7.6% ± 2.0%; P < 0.001). Adverse muscle composition was present in 36% of participants with HF compared with 17% of controls (P < 0.001). Muscle volume was also lower in the HF group (z-score, −0.7 ± 1.0 vs −0.1 ± 0.9; P < 0.001). Body composition patterns differed across HF phenotypes. HFmrEF was associated with the highest visceral adipose tissue levels and lowest muscle volume. HFpEF showed greater overall fat and muscle fat infiltration, whereas HFrEF had the highest prevalence of adverse muscle composition and the weakest grip strength.
Despite the MRI-detected muscle abnormalities, the estimated prevalence of sarcopenia varied considerably according to the diagnostic criteria applied, highlighting inconsistencies among current definitions.
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Source: Butler, J., Fioretti, F., Anker, S. D., et al. Body Composition in Heart Failure: A Magnetic Resonance Imaging and Dual X-Ray Absorptiometry Assessment in the UK Biobank Study. JACC: Heart Failure. 2026; 14(10): 103242. Published: October, 2026. DOI: 10.1016/j.jchf.2026.103242.
Hormone Therapy in Premature Ovarian Insufficiency and Early Menopause
A joint FIGO-IMS position paper emphasizes that hormone therapy in premature ovarian insufficiency and early menopause should extend beyond symptom relief to address the long-term consequences of estrogen deficiency. Individualized estrogen replacement may support bone health and healthy aging, while important questions about cardiovascular outcomes and optimal treatment regimens remain under investigation.
Summary
A Paradigm for Healthy Aging
[Posted 6/Oct/2026]
AUDIENCE: Ob/Gyn, Endocrinology, Internal Medicine
KEY FINDINGS: Key Information The FIGO-IMS position paper reframes hormone therapy in POI and early menopause as replacement of prematurely lost ovarian hormones, with potential implications for healthy aging. Treatment decisions should consider age at ovarian insufficiency, symptoms, bone health, cardiovascular risk, uterine status, reproductive goals, and individual contraindications.
The evidence supports a comprehensive, individualized approach rather than assuming that regimens used for typical-age menopause are sufficient for younger women with prolonged estrogen deficiency. The authors also acknowledge important evidence gaps, particularly regarding long-term cardiovascular outcomes and comparative effectiveness of different hormone regimens.
BACKGROUND: Premature ovarian insufficiency (POI) and early menopause are associated with prolonged estrogen deficiency during years when ovarian hormone production would ordinarily continue. Beyond vasomotor symptoms and reproductive consequences, estrogen deficiency may affect skeletal, cardiovascular, metabolic, cognitive, and genitourinary health. Hormone therapy (HT) has traditionally been considered primarily for symptom control, but its role in replacing deficient ovarian hormones and supporting long-term health warrants broader clinical consideration.
A joint position paper from FIGO and the International Menopause Society (IMS) reviews current evidence and proposes a more comprehensive approach to hormone therapy in women with POI or early menopause.
DETAILS: The position paper examines the physiological rationale for estrogen replacement, the timing and duration of treatment, hormone formulation and route of administration, and the potential implications for bone and cardiovascular health. It discusses the distinction between hormone replacement in younger women with premature estrogen loss and conventional menopausal hormone therapy initiated around the usual age of menopause. The authors review evidence supporting physiological estradiol replacement, including transdermal 17β-estradiol at 100 micrograms per day or oral 17β-estradiol at 2-4 mg per day. The paper also addresses the need for progestogen protection in women with an intact uterus, individualization of treatment, fertility considerations, and the limitations of available evidence concerning long-term cardiovascular outcomes and comparisons between HT and combined oral contraceptives.
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The position paper emphasizes that hormone therapy in women with POI or early menopause should be considered an important component of long-term health management, rather than solely a treatment for vasomotor symptoms. Physiological estrogen replacement may help maintain bone mineral density and address consequences of premature estrogen deficiency. The authors discuss evidence that transdermal estradiol at 100 micrograms per day can restore lumbar spine and femoral neck bone mineral density to normal levels in women with POI. However, evidence regarding the superiority of higher estrogen doses for all skeletal outcomes remains inconsistent, and comparative data on major cardiovascular outcomes are limited.
The paper also highlights the need for further research comparing hormone therapy with combined oral contraceptives and evaluating long-term health outcomes, treatment acceptability, and optimal regimens.
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Source: Benedetto, C., Khadilkar, S. S., Nappi, R. E., et al. Hormone therapy (HT) in women with premature ovarian insufficiency or early menopause: Time to think of a new paradigm for healthy aging. Journal of Gynecology & Obstetrics.. 2026; 175(1): 26-47. Published: October, 2026. DOI: 10.1002/ijgo.71217.
Timing of Vascular Access Creation in Older Adults With ESKD
A prospective European cohort of older adults with ESKD found that only 32% of AVFs were created within the defined 6-month window before hemodialysis initiation, while 42% were created early and 26% late. The findings highlight the difficulty of predicting dialysis timing and the need for better tools to individualize vascular access planning.
KEY FINDINGS: In this European cohort of older adults with ESKD, vascular access creation frequently did not coincide with the timing of hemodialysis initiation. More than 4 in 10 AVFs were created early, while approximately 1 in 4 were created late, resulting in substantial use of CVCs at dialysis initiation. The findings highlight the difficulty of predicting dialysis initiation in older adults and support the development of clinical prediction tools to better individualize vascular access planning.
BACKGROUND: Planning vascular access for older adults with end-stage kidney disease (ESKD) is challenging because the timing of hemodialysis initiation is difficult to predict. Arteriovenous fistulas (AVFs) created too early may remain unused, whereas delayed creation can result in hemodialysis being initiated through a central venous catheter (CVC). This study evaluated the timing of vascular access creation relative to hemodialysis initiation in older patients across Europe.
DETAILS: This secondary analysis used data from the EQUAL cohort, a prospective observational study involving patients aged 65 years or older with stage 4 or 5 chronic kidney disease in six European countries. Patients were included when their estimated glomerular filtration rate fell below 15 mL/min/1.73 m², provided they received a vascular access and had at least 6 months of follow-up. AVF timing was categorized as early when hemodialysis did not begin within 6 months after AVF creation, on time when hemodialysis was initiated with an AVF within 6 months, and late when hemodialysis was initiated with a CVC before or within 6 months after AVF creation.
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A total of 332 patients were analyzed. An AVF was the first vascular access in 221 patients (67%), while 111 patients (33%) initially received a CVC. Among those initially receiving a CVC, 53 patients (48%) subsequently underwent AVF creation. At dialysis initiation, 158 patients (54%) were using an AVF and 136 (46%) were using a CVC. Among the 274 patients who underwent AVF creation, access was created on time in 88 patients (32%), early in 114 (42%), and late in 72 (26%). Despite the high proportion of early AVF creation, most fistulas were eventually used, with 90% of patients initiating hemodialysis within 3 years after AVF creation.
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Source: Heggen, B. D. C., Chesnaye, N. C., Dekker, F. W., et al. Vascular Access Surgery Timing: A Prospective European Cohort Study in Elderly Patients with ESKD. Kidney360. 2026; 7(9): 2066-2074. Published: September 22, 2026. DOI: 10.34067/KID.0000001180.
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