Ubiquitin-conjugating enzyme 9 (Ubc9) is required for sumoylation and is overexpressed in several malignancies, but its expression in hepatocellular carcinoma (HCC) is unknown. Hepatic S -adenosyl methionine (SAMe) levels decrease in methionine adenosyltransferase 1A ( Mat1a ) knockout (KO) mice, which develop HCC, and in ethanol-fed mice. We examined the regulation of Ubc9 by SAMe in murine liver and human HCC, breast, and colon carcinoma cell lines and specimens. Real-time polymerase chain reaction and western blotting measured gene and protein expression, respectively. Immunoprecipitation followed by western blotting examined protein-protein interactions. Ubc9 expression increased in HCC and when hepatic SAMe levels decreased. SAMe treatment in Mat1a KO mice reduced Ubc9 protein, but not messenger RNA (mRNA) levels, and lowered sumoylation. Similarly, treatment of liver cancer cell lines HepG2 and Huh7, colon cancer cell line RKO, and breast cancer cell line MCF-7 with SAMe or its metabolite 5′-methylthioadenosine (MTA) reduced only Ubc9 protein level. Ubc9 posttranslational regulation is unknown. Ubc9 sequence predicted a possible phosphorylation site by cell division cycle 2 (Cdc2), which directly phosphorylated recombinant Ubc9. Mat1a KO mice had higher phosphorylated (phospho)-Ubc9 levels, which normalized after SAMe treatment. SAMe and MTA treatment lowered Cdc2 mRNA and protein levels, as well as phospho-Ubc9 and protein sumoylation in liver, colon, and breast cancer cells. Serine 71 of Ubc9 was required for phosphorylation, interaction with Cdc2, and protein stability. Cdc2, Ubc9, and phospho-Ubc9 levels increased in human liver, breast, and colon cancers. Conclusion: Cdc2 expression is increased and Ubc9 is hyperphosphorylated in several cancers, and this represents a novel mechanism to maintain high Ubc9 protein expression that can be inhibited by SAMe and MTA.

Introduction and importance: Heterotopic pancreas (HP) is defined as the presence of pancreatic tissue without anatomical and vascular continuity with the main body of the pancreas. HP typically remains asymptomatic, however complications such as acute pancreatitis can arise. Gastrointestinal involvement with coronavirus disease 2019 (COVID-19) is not uncommon and there are reported cases of associated pancreatitis. Case presentation: A 31-year-old male presented to the Emergency department (ED) with a 3-day history of right iliac fossa pain. The patient was found to have COVID-19 and a planned laparoscopic appendectomy was later converted to a midline laparotomy when a mass close to the duodeno-jejunal (DJ) flexure was identified. Following a hand-sewn anastomosis the patient made a good post-operative recovery. Histology illustrated the presence of heterotopic pancreatic tissue within the small bowel with underlying fat necrosis typical of acute pancreatitis. Follow-up radiology supported the intraoperative finding of intestinal malrotation. Clinical discussion: Rarely the combined presence of intestinal malrotation and HP in patients has been noted. Heterotopic pancreatitis can present in a multitude of ways and it is a difficult diagnosis to make pre-operatively. Emerging literature documents the potential presentation of COVID-19 with acute pancreatitis. The expression of angiotensin-converting enzyme 2 (ACE2) receptors on the pancreas is believed to play a role. Conclusion: This is the first documented case of heterotopic pancreatitis with intestinal malrotation in a COVID-19 positive patient. We hypothesise that the COVID-19 infection contributed to the heterotopic pancreatitis. Highlights:

Background/Objectives: Older adults frequently present with emergency ventral hernias, a situation that carries significant physiological risks and often requires challenging clinical decisions. Despite the prevalence of these cases, there is a lack of robust evidence to inform emergency care in this demographic, as most existing research centres on short-term mortality rates and operative variables. Key aspects such as the impact of frailty and the course of recovery following surgery are insufficiently addressed in the literature. This study aimed to describe management strategies, frailty burden and postoperative outcomes in older adults presenting with emergency ventral hernias. Methods: This study retrospectively examined patients aged 65 and older who were admitted to a UK tertiary centre with emergency ventral hernias from February 2016 to July 2024. Data, including patient demographics, comorbid conditions, frailty status (as measured by the Clinical Frailty Scale), management approach, healthcare resource use, and clinical outcomes, were analysed descriptively. Additionally, a structured literature review was conducted in accordance with PRISMA guidelines to identify research on emergency ventral hernia treatment outcomes in adults aged 60 years and older. Results: A total of 67 patients met the inclusion criteria for the cohort. High rates of frailty and multiple coexisting health conditions were observed. While surgical intervention was the predominant management strategy, a subset of patients received conservative or palliative care. Greater degrees of frailty correlated with longer hospital stays and an increased need for critical care, even though six-month mortality remained comparatively low. Traditional risk assessment tools tended to overpredict mortality risk and failed to reflect the true postoperative burden or the recovery process. The systematic review yielded 7 studies, most of which documented mortality and complication rates, but few addressed frailty or provided detailed postoperative recovery data. Conclusions: The management of emergency ventral hernias in older adults is highly variable, with a significant postoperative impact that extends beyond mortality statistics. Assessing frailty appears to provide additional information that may support clinical decision-making and help anticipate recovery after surgery. Integrating frailty evaluation into emergency hernia care could enhance multidisciplinary collaboration and help ensure that treatment plans are better tailored to patient vulnerability and individual care goals.

Background: Acute colonic pseudo-obstruction (ACPO) is a rare but clinically significant cause of acute colonic dilatation without mechanical obstruction. Older adults and patients living with frailty are particularly vulnerable to complications, including perforation, sepsis, and death. Despite guideline recommendations, variability persists in diagnostic pathways and therapeutic decision-making. This study reports a 10-year experience of ACPO management at a large UK tertiary referral center and evaluates the relationship between frailty, treatment escalation, and mortality. An exploratory cohort of ACPO cases associated with COVID-19 infection was also examined to explore how highly monitored critical care settings may influence treatment patterns. Materials and Methods: A retrospective cohort study identified adults with radiologically confirmed ACPO between January 2009 and March 2019. Demographic, clinical, management, and outcome data were extracted from electronic health records and imaging systems. The primary outcome was 30-day all-cause mortality. Secondary outcomes included escalation of care (endoscopy or surgery), resolution following conservative or pharmacological therapy, recurrence within 12 months, and 6-month mortality. Frailty was retrospectively assessed using the Clinical Frailty Scale (CFS) in patients aged ≥65 years ( n = 27), consistent with institutional frailty assessment practices. Multivariable logistic regression was used to examine associations between CFS, cecal diameter, escalation of care, and early mortality. A separate exploratory cohort of critically ill patients who developed ACPO during COVID-19 infection between 2020 and 2021 was analyzed descriptively. Results: Forty-eight patients met the inclusion criteria (median age 81 years; 56.0% women), and 71.0% developed ACPO during hospitalization. Endoscopic decompression was performed in 52.0% of patients, with a success rate of 72.0%. Neostigmine was administered in 12.5% of cases despite 37 patients meeting eligibility criteria; treatment success was 83.0%. Surgery was required in 10.0% of cases, mainly due to perforation or ischemia. Among patients aged ≥65 years with available frailty assessments, higher frailty was associated with increased 30-day mortality (44.0% with CFS ≥ 6 vs 8.0% with CFS < 6). In multivariable analysis, increasing CFS (aOR 1.42 per point, 95% CI 1.05–1.93) and cecal diameter ≥12 cm (aOR 3.08, 95% CI 1.01–9.41) were independently associated with early mortality. In the exploratory COVID-19 cohort ( n = 11), all patients received neostigmine, and none required surgery. Conclusions: Higher frailty and greater cecal dilatation were associated with early mortality in patients with ACPO. Neostigmine use in routine practice appeared inconsistent outside highly monitored settings. These observations suggest that a structured, frailty-informed management approach may support clinical decision-making; however, prospective studies are required to determine whether such pathways improve outcomes in older and multimorbid patients.