The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System

Novel Preoperative Risk Stratification Using Digital Phenotyping Applying a Scalable Machine-Learning Approach

BACKGROUND

Classification of perioperative risk is important for patient care, resource allocation, and guiding shared decision-making. Using discriminative features from the electronic health record (EHR), machine-learning algorithms can create digital phenotypes among heterogenous populations, representing distinct patient subpopulations grouped by shared characteristics, from which we can personalize care, anticipate clinical care trajectories, and explore therapies. We hypothesized that digital phenotypes in preoperative settings are associated with postoperative adverse events including in-hospital and 30-day mortality, 30-day surgical redo, intensive care unit (ICU) admission, and hospital length of stay (LOS).

METHODS

We identified all laminectomies, colectomies, and thoracic surgeries performed over a 9-year period from a large hospital system. Seventy-seven readily extractable preoperative features were first selected from clinical consensus, including demographics, medical history, and lab results. Three surgery-specific datasets were built and split into derivation and validation cohorts using chronological occurrence. Consensus k -means clustering was performed independently on each derivation cohort, from which phenotypes' characteristics were explored. Cluster assignments were used to train a random forest model to assign patient phenotypes in validation cohorts. We reconducted descriptive analyses on validation cohorts to confirm the similarity of patient characteristics with derivation cohorts, and quantified the association of each phenotype with postoperative adverse events by using the area under receiver operating characteristic curve (AUROC). We compared our approach to American Society of Anesthesiologists (ASA) alone and investigated a combination of our phenotypes with the ASA score.

RESULTS

A total of 7251 patients met inclusion criteria, of which 2770 were held out in a validation dataset based on chronological occurrence. Using segmentation metrics and clinical consensus, 3 distinct phenotypes were created for each surgery. The main features used for segmentation included urgency of the procedure, preoperative LOS, age, and comorbidities. The most relevant characteristics varied for each of the 3 surgeries. Low-risk phenotype alpha was the most common (2039 of 2770, 74%), while high-risk phenotype gamma was the rarest (302 of 2770, 11%). Adverse outcomes progressively increased from phenotypes alpha to gamma, including 30-day mortality (0.3%, 2.1%, and 6.0%, respectively), in-hospital mortality (0.2%, 2.3%, and 7.3%), and prolonged hospital LOS (3.4%, 22.1%, and 25.8%). When combined with the ASA score, digital phenotypes achieved higher AUROC than the ASA score alone (hospital mortality: 0.91 vs 0.84; prolonged hospitalization: 0.80 vs 0.71).

CONCLUSIONS

For 3 frequently performed surgeries, we identified 3 digital phenotypes. The typical profiles of each phenotype were described and could be used to anticipate adverse postoperative events.

Comparative efficacy of opioid and non-opioid analgesics in labor pain management: A network meta-analysis

BACKGROUND

Effective labor pain management is crucial for parturient well-being, as it can improve the delivery experience of pregnant women and reduce anxiety and tension. This systematic review and network meta-analysis compared the efficacy and safety of various analgesics, classified by drug category and individual treatment methods, for labor pain control.

METHODS

A comprehensive literature search was conducted in Pubmed, EMBASE, Cochrane Library, and Web of Science databases. All searches commenced from the database's inception to the date of the literature search (May 31, 2023). The Cochrane Risk of Bias 2 tool assessed study bias risk. Network meta-analyses using a random-effects model and odds ratios (ORs) with 95% confidence intervals (CIs) were performed.

RESULTS

Fifteen randomized controlled trials evaluating analgesic interventions in ASA I or II parturients were included. Combination therapies (OR: 5.81; 95% CI, 3.76-7.84; probability: 60%) and non-opioid analgesics (OR: 5.61; 95% CI, 2.91-8.30; probability: 39.2%) were superior to placebo for labor pain relief. Specifically, dexmedetomidine/ropivacaine/sufentanil (OR: 7.32; 95% CI, 2.73-11.89; probability: 40.6%) and dexmedetomidine/ropivacaine (OR: 6.50; 95% CI, 2.51-10.33; probability: 11.9%) combinations, bupivacaine/fentanyl and ropivacaine/sufentanil combinations, and remifentanil monotherapy showed improved analgesic efficacy versus placebo. Dexmedetomidine/ropivacaine reduced parturient nausea and vomiting versus alternatives.

CONCLUSION

Non-opioids, opioids and combinations thereof effectively relieved labor pain. In addition, dexmedetomidine/ropivacaine combination demonstrated analgesic efficacy and lower nausea and vomiting incidence.

Risk Factors for Reintubation After Anterior Cervical Spine Surgery: Comparative Study of Patients With Cervical Spine Trauma and Patients With Cervical Degenerative Disease

STUDY DESIGN

Single-center retrospective study.

OBJECTIVES

The aim was to compare the postoperative outcomes of anterior cervical spine surgery (ACSS) in patients with and without cervical spine trauma.

SUMMARY OF BACKGROUND

Few papers have addressed airway obstruction after anterior ACSS for patients with cervical spine trauma. This study aimed to compare airway obstruction after ACSS between patients with cervical degenerative disorders and cervical spine injuries and identify the risk factors for unplanned postoperative reintubation.

MATERIALS AND METHODS

Seventy-seven patients who underwent ACSS were enrolled in this retrospective study. There were 52 men and 25 women, with a mean age of 60.3±15.5 years old. The causes of surgery were as follows: 24 cervical spine fractures or dislocations, 12 spinal cord injuries without bony fracture, 19 disc herniations, and 22 myelopathies. The patients' characteristics, operative data, and risk factors for unplanned reintubation within 5 days postoperatively were analyzed using medical records.

RESULTS

Postoperative reintubation was performed in 3 patients (3.9%), all of whom suffered trauma. We further examined risk factors for reintubation in patients in the trauma group. There was no significant difference between the reintubation (R) and nonreintubation (non-R) groups in age, sex, body mass index, amount of blood loss and operation time, preoperative paralysis severity, and the number of fused segments. Patients in group R had significantly higher rates of severe anterior element injury (100% vs. 27.3%, P =0.0011). Airway obstruction due to laryngopharyngeal edema and swelling was confirmed by laryngoscopy and computed tomography images.

CONCLUSIONS

Unplanned reintubation after ACSS occurred at a higher rate in trauma patients than in patients with degenerative disorders. Our results suggested that the severe damage to the anterior element of the cervical spine was associated with postoperative reintubation.

EVIDENCE LEVEL

Level IV.

Effect of PI3K/AKT/mTOR signaling pathway-based clustered nursing care combined with papaverine injection on vascular inflammation and vascular crisis after replantation of severed fingers

This research aimed to investigate the effect of PI3K (phosphatidylinositol 3-kinase)/AKT (protein kinase B)/mTOR (mammalian target protein of rapamycin) signaling pathway-based clustering care combined with papaverine injection on vascular inflammation and vascular crisis after finger amputation and replantation. 100 patients admitted in General Hospital of Ningxia Medical University from April 2022 to December 2022 for replantation of severed fingers were selected and divided into a control group (n = 50) and an observation group (n = 50) using the randomized grouping principle. The control group received a papaverine injection and general nursing care, the observation group received a papaverine injection and clustered care. The pain score; constipation incidence; replantation finger survival rate; physician, nurse, and patient satisfaction; serum inflammatory factors; vascular crisis parameters; and occurrence of adverse reactions were compared between the two patient groups. Enzyme-linked immunosorbent assay was performed to detect PI3K, AKT, and mTOR protein concentrations in the venous blood of the two groups, and statistical analysis of the data was performed. On postoperative day 7, the pain score and incidence of constipation in the observation group were lower than those in the control group (P < 0.05); the survival rate of reimplanted fingers in the observation group was 88.00%, which was higher than that in the control group 80.00% (P < 0.05); the satisfaction of doctors, nurses, and patients in the observation group was higher than that in the control group; the concentrations of interleukin-1 (IL-1), tumor necrosis factor (TNF-α), blood flow resistance index (RI), and arterial pulsatility index (PI) in the observation group were lower than those in the control group, while the concentration of interleukin-10 (IL-10), vascular diameter, and Vm (mean blood flow velocity) were higher in the observation group than those in the control group; the differences were statistically significant (P < 0.05). The difference in the incidence of adverse reactions between the two groups was not statistically significant (P > 0.05). The concentrations of PI3K, AKT, and mTOR proteins in the observation group were higher than those in the control group (P < 0.05). The concentrations of PI3K, AKT, and mTOR proteins in the observation group were higher than those in the control group (P < 0.05). Overall, these findings suggest that clustered care combined with papaverine injection reduces vascular inflammatory symptoms and vascular crisis in the treatment of severed finger replantation through the PI3K/AKT/mTOR signaling pathway.

Surgical Outcomes and Complications of Myomectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To investigate postoperative surgical and non-surgical complications that occur within 30 days following myomectomy procedures, whether laparoscopic or via open surgery.

DESIGN

Prospective cohort study SETTING: Del Ponte Women's and Children's Hospital, Varese, Italy.

PATIENTS

Women undergoing myomectomy either with laparoscopic or open surgery from July 2020 to June 2023 INTERVENTIONS: Data of consecutive patients who underwent abdominal myomectomy procedures, either via laparoscopy or open abdominal surgery were collected. The study examined patient characteristics, size and location of fibroids, surgical data, and complications. Univariate and multivariable analyses were employed to identify factors contributing to postoperative Clavien-Dindo grade ≥ II complications.

MEASUREMENTS AND MAIN RESULTS

Overall 383 patients were included in the study. The univariate analysis showed intramural fibroid type (p = .0009), large fibroid size (p = .03), and extended operative times (p = .05) were associated with postoperative complications. Open surgical approach (p <.001) and uterine cavity opening (p = .02) also contributed to complications. Postoperative anemia emerged as the most prevalent complication. In the multivariable analysis, the open surgical approach emerged as the only independent factor associated with an increased risk of grade ≥ II complications (odds ratio 7.37; p <.0001).

CONCLUSION

In this study we found an increased likelihood of complications in case of open myomectomy. While the presence of potential selection bias may have impacted this finding, it could provide valuable insights for clinicians and surgical teams in the strategic planning of myomectomy procedures.

Suggestion for Determining Treatment Strategies in Dental Ethics

Contemporary medicine views health as the individual's physical, mental, and social well-being. Oral health plays a crucial role in one's well-being, as the oral cavity and its surrounding regions execute essential functions in verbal and nonverbal communication, sensing, digestion, and significantly contribute to aesthetic appearance. The multifaceted nature of the notion of oral health, as well as the patient's needs and autonomous will result in various treatment options for the same oral state, favouring often contrasting ethical values and different aspects of oral health. The objective of this article is to suggest alternative treatment strategies in dentistry with respect to the following factors: extent of rehabilitation, preserving one's anatomical structures, aesthetic outcome, number of sessions, patient autonomy. Additionally, this article describes the suggested treatment strategies in an ethical context and determines the conditions of their employment. The suggested treatment strategies are divided in two categories, extensive treatment strategies focusing on the patient's entire craniofacial complex, while specific treatment strategies focus on specific paramount issues.

Assessment of Hidden Blood Loss in Spinal Metastasis Surgery: A Comprehensive Approach with MRI-Based Radiomics Models

BACKGROUND

Patients undergoing surgery for spinal metastasis are predisposed to hidden blood loss (HBL), which is associated with poor surgical outcomes but unpredictable.

PURPOSE

To evaluate the role of MRI-based radiomics models for assess the risk of HBL in patients undergoing spinal metastasis surgery.

STUDY TYPE

Retrospective.

SUBJECTS

202 patients (42.6% female) operated on for spinal metastasis with a mean age of 58 ± 11 years were divided into a training (n = 162) and a validation cohort (n = 40).

FIELD STRENGTH/SEQUENCE

1.5T or 3.0T scanners. Sagittal T1-weighted and fat-suppressed T2-weighted imaging sequences.

ASSESSMENT

HBL was calculated using the Gross formula. Patients were classified as low and high HBL group, with 1000 mL as the threshold. Radiomics models were constructed with radiomics features. The radiomics score (Radscore) was obtained from the optimal radiomics model. Clinical variables were accessed using univariate and multivariate logistic regression analyses. Independent risk variables were used to build a clinical model. Clinical variables combined with Radscore were used to establish a combined model.

STATISTICAL TESTS

Predictive performance was evaluated using area under the curve (AUC), accuracy, sensitivity, specificity, and F1 score. Calibration curves and decision curves analyses were produced to evaluate the accuracy and clinical utility.

RESULTS

Among the radiomics models, the fusion (T1WI + FS-T2WI) model demonstrated the highest predictive efficacy (AUC: 0.744, 95% confidence interval [CI]: 0.576-0.914). The Radscore model (AUC: 0.809, 95% CI: 0.664-0.954) performs slightly better than the clinical model (AUC: 0.721, 95% CI: 0.524-0.918; P = 0.418) and the combined model (AUC: 0.752, 95% CI: 0.593-0.911; P = 0.178).

DATA CONCLUSION

A radiomics model may serve as a promising assessment tool for the risk of HBL in patients undergoing spinal metastasis surgery, and guide perioperative planning to improve surgical outcomes.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Glucagon-Like Peptide-1 Receptor Agonist Use and Residual Gastric Content Before Anesthesia

Importance

Glucagon-like peptide-1 receptor agonist (GLP-1 RA) use is rapidly increasing in the US, driven by its expanded approval for weight management in addition to hyperglycemia management in patients with type 2 diabetes. The perioperative safety of these medications, particularly with aspiration risk under anesthesia, is uncertain.

Objective

To assess the association between GLP-1 RA use and prevalence of increased residual gastric content (RGC), a major risk factor for aspiration under anesthesia, using gastric ultrasonography.

Design, Setting, and Participants

This cross-sectional study prospectively enrolled patients from a large, tertiary, university-affiliated hospital from June 6 through July 12, 2023. Participants followed preprocedural fasting guidelines before an elective procedure under anesthesia. Patients with altered gastric anatomy (eg, from previous gastric surgery), pregnancy, recent trauma (<1 month), or an inability to lie in the right lateral decubitus position for gastric ultrasonography were excluded.

Exposure

Use of a once-weekly GLP-1 RA.

Main Outcomes and Measures

The primary outcome was the presence of increased RGC, defined by the presence of solids, thick liquids, or more than 1.5 mL/kg of clear liquids on gastric ultrasonography. Analysis was adjusted for confounders using augmented inverse probability of treatment weighting, a propensity score-based technique. Secondarily, the association between the duration of drug interruption and the prevalence of increased RGC was explored.

Results

Among the 124 participants (median age, 56 years [IQR, 46-65 years]; 75 [60%] female), the prevalence of increased RGC was 56% (35 of 62) in patients with GLP-1 RA use (exposure group) compared with 19% (12 of 62) in patients who were not taking a GLP-1 RA drug (control group). After adjustment for confounding, GLP-1 RA use was associated with a 30.5% (95% CI, 9.9%-51.2%) higher prevalence of increased RGC (adjusted prevalence ratio, 2.48; 95% CI, 1.23-4.97). There was no association between the duration of GLP-1 RA interruption and the prevalence of increased RGC (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14).

Conclusions and Relevance

Use of a GLP-1 RA was independently associated with increased RGC on preprocedural gastric ultrasonography. The findings suggest that the preprocedural fasting duration suggested by current guidelines may be inadequate in this group of patients at increased risk of aspiration under anesthesia.

Hematopoietic stem cell transplantation: an Italian monocentric experience on the health assessment and eligibility of adult-related donors

Introduction

Indications for HSCT are increasing worldwide, paralleled by a growing demand for donors of therapeutic cells.

Methods

Herein, we report our real-world experience of adult HPC donor assessment during a 5-year study period (2018-2023): we have retrospectively revised data of 455 potential related stem cell donors, consecutively evaluated at our center. Donor medical history was assessed by a questionnaire and an interview with a trained physician experienced in donation procedures to evaluate donor fitness and medical history. Pre-existing health disorders were fully investigated. Behavioral risk factors for communicable infectious diseases were also routinely explored.

Results and discussion

Overall, 351 donors were finally assessed as eligible for HPC donation, and 233 underwent stem cell collection, 158 through apheresis from mobilized peripheral blood, and 75 through bone marrow harvest. Among them, 27 donors were selected despite the presence of pre-existing health conditions, which would be potential exclusion criteria for unrelated donors: 16 suffered from well-controlled cardiovascular diseases (CVD) and 11 from allergic diathesis. Most of the selected donors with pre-existing disorders were candidates for apheresis HPC collection (21, 77.8%), while only six (22.2%) underwent BM harvest. We then analyzed the data relative to the corresponding 233 allogeneic HSCT to explore if the presence of pre-existing diseases in the donors could show any association with transplant characteristics. Transplants from CVD and allergy donors showed no significant disparities in comparison with those from healthy donors. A significant difference emerged regarding the disease severity, with a higher proportion of patients with high/very high disease risk index (DRI) among those receiving grafts from CVD donors (68.7% in transplants from CVD donors versus 36.0% in transplants from healthy donors, p=0.005). Multivariate analysis confirmed that high/very high DRI patients had an increased probability of receiving donations from CVD donors (OR, 4.89; 95%CI, 1.15-20.86; p=0.031). Among donors with well-controlled pre-existing conditions, no adverse events were recorded during stem cell collection or at follow-up. Our results suggest that in patients at high risk for relapse requiring a prompt allogeneic transplant, a familiar donor might be accepted for HPC apheresis donation on less strict criteria than unrelated donors, without risk for both donor and patient.

Improvement in Accuracy and Concordance of American Society of Anesthesiologist's Physical Status (ASA-PS) Scoring Assignment over a 11 Year Time Period Using Patient BMI as a Comorbidity Finding

Background

Anesthesia providers categorize patients utilizing the American Society of Anesthesiologists Physical Status (ASA-PS) classification originally created by the ASA in 1941. There is published variability and discordance among providers when assigning patient ASA scores in part due to the subjectivity of scoring utilizing patient medical conditions, but variability is also found using objective findings like BMI. To date, there are few studies evaluating the accuracy of anesthesia providers' ASA assignment based on objective body mass index (BMI) alone. The aim of this retrospective chart review is to determine improvement in accuracy of anesthesia providers to correctly assign patient ASA scores, based on BMI criteria added to the ASA-PS in October of 2014, utilizing a multifaceted strategy including creation of an active finance committee in the fall of 2015, multiple e-mail communications about the updated definitions and recommendations for ASA-PS scoring in the fall of 2015 and spring of 2016, a department grand rounds presentation in February 2016, placement of laminated copies of the ASA definitions and recommendations in the anesthesia chartrooms, and the development of a tool embedded into our EMR providing a recommendation of ASA-PS based on patient comorbidity findings.

Methods

After attaining IRB approval, all eligible patients over the age of 18 who had surgical procedures under general anesthesia at Mayo Clinic in Rochester, MN, between January 1, 2010, and December 31, 2020, were retrospectively analyzed. A segmented logistic regression model was used to estimate the trends (per-year change in odds) of ASA under classification according to severity of obesity during 3 epochs: preimplementation (2010-2014), implementation (2015), and postimplementation (2016-2020).

Results

A total of 16,467 patients of the 200,423 (8.2%) patients with obesity (class 1, 2, and 3) were underscored based on BMI alone. Accuracy of ASA-PS classification, as it pertains to BMI alone, was found to show meaningful improvement year-to-year following the updated ASA-PS guidelines with examples released in October of 2014 (P < 0.001). Most of the improvement occurred in 2015-2017 with relatively little between-year variability in the rate of underscoring from 2017-2020.

Conclusion

Despite updated ASA-PS published guidelines, providers may still be unaware of the updated guidelines and inclusion of examples used within the ASA-PS classification system. Accuracy of scoring did improve annually following the release of the updated guidelines with examples as well as department-wide educational activities on the topic. Additional education and awareness should be offered to those responsible for preanesthesia evaluation and assignment of ASA-PS in patients to improve accuracy as it pertains to BMI.

The safety and short-term effect of mixed approach in laparoscopic right hemicolectomy for right colon cancer compared with middle approach: a retrospective study

PURPOSE

To investigate whether the mixed approach is a safe and advantageous way to operate laparoscopic right hemicolectomy.

METHODS

A retrospective study was performed on 316 patients who underwent laparoscopic right hemicolectomy in our center. They were assigned to the middle approach group (n = 158) and the mixed approach group (n = 158) according to the surgical approaches. The baseline data like gender、age and body mass index as well as the intraoperative and postoperative conditions including operation time, blood loss, postoperative hospital stay and complications were analyzed.

RESULTS

There were no significant differences in age, sex, BMI, ASA grade and tumor characteristics between the two groups. Compared with the middle approach group, the mixed approach group was significantly lower in terms of operation time (217.61 min vs 154.31 min, p < 0.001), intraoperative blood loss (73.8 ml vs 37.97 ml, p < 0.001) and postoperative drainage volume. There was no significant difference in the postoperative complications like postoperative anastomotic leakage, postoperative infection and postoperative intestinal obstruction.

CONCLUSIONS

Compared with the middle approach, the mixed approach is a safe and advantageous way that can significantly shorten the operation time, reduce intraoperative bleeding and postoperative drainage volume, and does not prolong the length of hospital stay or increase the morbidity postoperative complications.

Neurosurgical treatment and outcome patterns in patients with meningioma in South Moravian region-a population-based study

INTRODUCTION

Meningiomas are usually slow-growing tumours, constituting about one third of all primary intracranial tumours. They occur more frequently in women. Clinical manifestation of meningiomas depends on their location, tumour size and growth rate. In most cases, surgical treatment is the procedure of choice. The success of this treatment is, however, associated with the radicality of the resection. Radiotherapy represents an additional or alternative treatment modality. Gamma knife surgery is another notable treatment method, especially in small and/or slow-growing tumours in eloquent areas or in elderly patients.

MATERIAL AND METHODS

Authors describe their experience with the diagnosis, treatment and outcome of the patients with meningioma (n = 857). Furthermore, they also assess the postoperative morbidity/mortality and recurrence rate.

RESULTS AND CONCLUSIONS

In view of the benign histology of meningiomas, the success of the treatment largely depends (besides the tumour grading) on the radicality of the resection. The emphasis is also put on appropriate follow-up of the patients. In certain patients, the watch and wait strategy should be also considered as a suitable treatment method.

The Impact of the COVID-19 Pandemic on Ambulatory Lumbar Spine Decompression Surgery

Background Only a few studies have examined the impact of the coronavirus disease 2019 pandemic on spine ambulatory surgeries and changes in trends. Therefore, we investigated trends during the pre-pandemic period and three pandemic stages in patients undergoing lumbar decompression procedures in the ambulatory surgery (AMS) setting. Methodology A total of 2,670 adult patients undergoing one- or two-level lumbar decompression surgery were retrospectively reviewed. Patients were categorized into the following four groups: 1: pre-pandemic (before the pandemic from January 1, 2019, to March 16, 2020); 2: restricted period (when elective surgery was canceled from March 17, 2020, to June 30, 2020); 3: post-restricted 2020 (July 1, 2020, to December 31, 2020, before vaccination); and 4: post-restricted 2021 (January 1, 2021 to December 31, 2021 after vaccination). Simple and multivariable logistic regression analyses as well as retrospective interrupted time series (ITS) analysis were conducted comparing AMS patients in the four periods. Results Patients from the restricted pandemic period were younger and healthier, which led to a shorter length of stay (LOS). The ITS analysis demonstrated a significant drop in mean LOS at the beginning of the restricted period and recovered to the pre-pandemic levels in one year. Multivariable logistic regression analyses indicated that the pandemic was an independent factor influencing the LOS in post-restricted phases. Conclusions As the post-restricted 2020 period itself might be independently influenced by the pandemic, these results should be taken into account when interpreting the LOS of the patients undergoing ambulatory spine surgery in post-restricted phases.

Clinical performance of preheating thermoviscous composite resin for non-carious cervical lesions restoration: A 24-month randomized clinical trial

OBJECTIVES

This 24-month, double-blind, split-mouth randomized clinical trial aimed to compare the retention rates of a preheated thermoviscous composite resin (PHT) compared to a non-heated composite resin (NHT) in non-carious cervical lesions (NCCLs).

METHODS

A total of 120 restorations were restored on NCCLs using a preheated (VisCalor bulk, Voco GmbH) and a non-heated (Admira Fusion, Voco GmbH) composite resins with 60 restorations per group. A universal adhesive in the selective enamel conditioning was applied. In the PHT group, composite was heated at 68 °C for using a bench heater. In the NHT group, no heating was employed. Both restorative materials were dispensed into caps and inserted into the NCCLs. The restorations were evaluated at baseline, 6, 12, 18, and after 24 months of clinical service using the FDI criteria. Statistical analysis was performed with Kaplan-Meier estimation analysis for retention/fracture rate and Chi-square test for the other FDI parameters (α=0.05).

RESULTS

After 24 months 108 restorations were assessed. Seven restorations were lost (two for PHT group and five for NHT group), and the retention rates (95 % confidence interval [CI]) were 96.7 % (81.5-99.9) for PHT group and 90.8 % (81.1-96.0) for NHT group, with no statistical differences between them (p > 0.05). The hazard ratio (95 % CI) was 0.52 (0.27 to 1.01), with no significant difference within groups. In terms of all other FDI parameters that were assessed, all restorations were deemed clinically acceptable.

CONCLUSIONS

Both composites showed high rates of retention rates after 24 months.

CLINICAL SIGNIFICANCE

The clinical performance of the new preheated thermoviscous was found to be as good as the non-heated composite after 24-month of clinical evaluation in non-carious cervical lesions.

REGISTRATION OF CLINICAL TRIALS

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Effect of Daytime versus Nighttime on Prehospital Care and Outcomes after Severe Traumatic Brain Injury

Background/Objectives: Severe traumatic brain injury (TBI) is a frequent cause of morbidity and mortality worldwide. In the Netherlands, suspected TBI is a criterion for the dispatch of the physician-staffed helicopter emergency medical services (HEMS) which are operational 24 h per day. It is unknown if patient outcome is influenced by the time of day during which the incident occurs. Therefore, we investigated the association between the time of day of the prehospital treatment of severe TBI and 30-day mortality. Methods: A retrospective analysis of prospectively collected data from the BRAIN-PROTECT study was performed. Patients with severe TBI treated by one of the four Dutch helicopter emergency medical services were included and followed up to one year. The association between prehospital treatment during day- versus nighttime, according to the universal daylight period, and 30-day mortality was analyzed with multivariable logistic regression. A planned subgroup analysis was performed in patients with TBI with or without any other injury. Results: A total of 1794 patients were included in the analysis, of which 1142 (63.7%) were categorized as daytime and 652 (36.3%) as nighttime. Univariable analysis showed a lower 30-day mortality in patients with severe TBI treated during nighttime (OR 0.74, 95% CI 0.60-0.91, p = 0.004); this association was no longer present in the multivariable model (OR 0.82, 95% CI 0.59-1.16, p = 0.262). In a subgroup analysis, no association was found between mortality rates and the time of prehospital treatment in patients with combined injuries (TBI and any other injury). Patients with isolated TBI had a lower mortality rate when treated during nighttime than when treated during daytime (OR 0.51, 95% CI 0.34-0.76, p = 0.001). Within the whole cohort, daytime versus nighttime treatments were not associated with differences in functional outcome defined by the Glasgow Outcome Scale. Conclusions: In the overall study population, no difference was found in 30-day mortality between patients with severe TBI treated during day or night in the multivariable model. Patients with isolated severe TBI had lower mortality rates at 30 days when treated at nighttime.

Play it safe: renal function after bilateral flexible ureteroscopy for kidney stones

PURPOSE

We searched for perioperative renal function deterioration risk factors in patients that underwent bilateral flexible ureteroscopy (fURS) for kidney stones.

METHODS

From August 2016 to February 2020, symptomatic patients > 18 years old with bilateral kidney stones up to 20 mm in each side were prospectively studied. Serum creatinine samples were collected on admission to surgery, immediate postoperative (IPO), on POD 3, 10, and 30. Estimated glomerular filtration rate (eGFR) was calculated using Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) without a race coefficient.

RESULTS

Thirty patients underwent bilateral fURS. Comparing to preoperative eGFR, median IPO and POD3 eGFR (p < 0.001) were significantly lower, and POD10 (p = 0.092) and POD30 (p = 0.648) were similar to preoperative eGFR. During follow-up, 22/30 (73.3%), 14/30 (46.7%), and 7/30 (23.3%) of the patients presented a decrease > 10% eGFR, > 20% eGFR, and > 30% eGFR, respectively. Multivariate analysis demonstrated that lower preoperative eGFR is a risk factor for eGFR < 60 mL/min/1.73 m2, p = 0.019 [1.021-1.263; 1.136]; ASA > 1 is a risk factor for decrease of eGFR > 10%, p = 0.028 [1.25-51.13; 8.00]; longer operative time is a risk factor for decrease of eGFR > 20%, p = 0.042 [1.00-1.05; 1.028]; and operative time ≥ 120 min is a risk factor for decrease of eGFR > 30%, p = 0.026 [0.016-0.773; 0.113].

CONCLUSIONS

Renal function suffers a reversible decrease after bilateral fURS. Our study suggests that adequate selection of patients and maintaining operative time < 120 min are relevant factors in preventing acute renal function deterioration following bilateral fURS.

Exploring the Median Effective Dose of Ciprofol for Anesthesia Induction in Elderly Patients: Impact of Frailty on ED50

Purpose

Explore the median effective dose of ciprofol for inducing loss of consciousness in elderly patients and investigate how frailty influences the ED50 of ciprofol in elderly patients.

Patients and Methods

A total of 26 non-frail patients and 28 frail patients aged 65-78 years, with BMI ranging from 15 to 28 kg/m2, and classified as ASA grade II or III were selected. Patients were divided into two groups according to frailty: non-frail patients (CFS<4), frail patients (CFS≥4). With an initial dose of 0.3 mg/kg for elderly non-frail patients and 0.25 mg/kg for elderly frail patients, using the up-and-down Dixon method, and the next patient's dose was dependent on the previous patient's response. Demographic information, heart rate (HR), oxygen saturation (SpO2), mean blood pressure (MBP), and bispectral index (BIS) were recorded every 30 seconds, starting from the initiation of drug administration and continuing up to 3 minutes post-administration. Additionally, the total ciprofol dosage during induction, occurrences of hypotension, bradycardia, respiratory depression, and injection pain were recorded.

Results

The calculated ED50 (95% confidence interval [CI]) and ED95 (95% CI) values for ciprofol-induced loss of consciousness were as follows: 0.267 mg/kg (95% CI 0.250-0.284) and 0.301 mg/kg (95% CI 0.284-0.397) for elderly non-frail patients; and 0.263 mg/kg (95% CI 0.244-0.281) and 0.302 mg/kg (95% CI 0.283-0.412) for elderly frail patients. Importantly, no patients reported intravenous injection pain, required treatment for hypotension, or experienced significant bradycardia.

Conclusion

Frailty among elderly patients does not exert a notable impact on the median effective dose of ciprofol for anesthesia induction. Our findings suggest that anesthesiologists may forego the necessity of dosage adjustments when administering ciprofol for anesthesia induction in elderly frail patients.

First knee for pain and function versus second knee for quality of life

Aims

The aim of this study was to describe and compare joint-specific and generic health-related quality of life outcomes of the first versus second knee in patients undergoing staged bilateral total knee arthroplasty (BTKA) for osteoarthritis.

Methods

This retrospective cohort study used Australian national arthroplasty registry data from January 2013 to January 2021 to identify participants who underwent elective staged BTKA with six to 24 months between procedures. The primary outcome was Oxford Knee Score (OKS) at six months postoperatively for the first TKA compared to the second TKA, adjusted for age and sex. Secondary outcomes compared six-month EuroQol five-dimension five-level (EQ-5D-5L) domain scores, EQ-5D index scores, and the EQ visual analogue scale (EQ-VAS) between knees at six months postoperatively.

Results

The cohort included 635 participants (1,270 primary procedures). Preoperative scores were worse in the first knee compared to the second for all instruments; however, comparing the first knee at six months postoperatively with the second knee at six months postoperatively, the mean between-knee difference was minimal for OKS (-0.8 points; 95% confidence interval (CI) -1.4 to -0.2), EQ-VAS (3.3; 95% CI 1.9 to 4.7), and EQ-5D index (0.09 points; 95% CI 0.07 to 0.12). Outcomes for the EQ-5D-5L domains 'mobility', 'usual activities', and 'pain/discomfort' were better following the second TKA.

Conclusion

At six months postoperatively, there were no clinically meaningful differences between the first and second TKA in either the joint-specific or overall generic health-related quality of life outcomes. However, individual domain scores assessing mobility, pain, and usual activities were notably higher after the second TKA, likely reflecting the cumulative improvement in quality of life after both knees have been replaced.

Pulmonary function testing in preoperative high-risk patients

BACKGROUND

Postoperative respiratory failure is the most frequent complication in postsurgical patients. The purpose of this study is to assess whether pulmonary function testing in high-risk patients during preoperative assessment detects previously unknown respiratory impairments which may influence patient outcomes.

METHODS

A targeted patient screening by spirometry and the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) was implemented in the anesthesia department of a tertiary university hospital. Patients of all surgical disciplines who were at least 75 years old or exhibited reduced exercise tolerance with the metabolic equivalent of task less than four (MET < 4) were examined. Clinical characteristics, history of lung diseases, and smoking status were also recorded. The statistical analysis entailed t-tests, one-way ANOVA, and multiple linear regression with backward elimination for group comparisons.

RESULTS

Among 256 included patients, 230 fulfilled the test quality criteria. Eighty-one (35.2%) patients presented obstructive ventilatory disorders, out of which 65 were previously unknown. 38 of the newly diagnosed obstructive disorders were mild, 18 moderate, and 9 severe. One hundred forty-five DLCO measurements revealed 40 (27.6%) previously unknown gas exchange impairments; 21 were mild, 17 moderate, and 2 severe. The pulmonary function parameters of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly lower than the international reference values of a healthy population. Patients with a lower ASA class and no history of smoking exhibited higher FVC, FEV1, and DLCO values. Reduced exercise tolerance with MET < 4 was strongly associated with lower spirometry values.

CONCLUSIONS

Our screening program detected a relevant number of patients with previously unknown obstructive ventilatory disorders and impaired pulmonary gas exchange. This newly discovered sickness is associated with low metabolic equivalents and may influence perioperative outcomes. Whether optimized management of patients with previously unknown impaired lung function leads to a better outcome should be evaluated in multicenter studies.

TRIAL REGISTRATION

German Registry of Clinical Studies (DRKS00029337), registered on: June 22nd, 2022.

Understanding New Machine Learning Architectures: Practical Generative Artificial Intelligence for Anesthesiologists

Recent advances in neural networks have given rise to generative artificial intelligence, systems able to produce fluent responses to natural questions or attractive and even photorealistic images from text prompts. These systems were developed through new network architectures that permit massive computational resources to be applied efficiently to enormous data sets. First, this review examines autoencoder architecture and its derivatives the variational autoencoder and the U-Net in annotating and manipulating images and extracting salience. This architecture will be important for applications like automated x-ray interpretation or real-time highlighting of anatomy in ultrasound images. Second, this article examines the transformer architecture in the interpretation and generation of natural language, as it will be useful in producing automated summarization of medical records or performing initial patient screening. The author also applies the GPT-3.5 algorithm to example questions from the American Board of Anesthesiologists Basic Examination and find that, under surprisingly reasonable conditions, it correctly answers more than half the questions.

Postoperative cognitive worsening in seniors with an age above life expectancy: a prospective longitudinal study

BACKGROUND

The growing number of elderly patients in hospitals is a challenge for healthcare systems. The main objective is to measure the postoperative change in the cognitive status at hospital discharge and one year after discharge in elderly patients undergoing planned or deferrable surgery.

METHODS

We planned a prospective longitudinal study, single-center study: secondary care level hospital, enrolment from September 2018 to May 2019. We enroll elderly patients, aged above life expectancy in Italy, who underwent planned or deferrable surgery (men over 80.5 years old, women over 85.0 years old). In six months, we enrolled 76 eligible patients. We collected the scores of the clinical impairment scales Charlson Index, Barthel Index, and Six-Item Cognitive Impairment Test (6CIT). The primary endpoint was the postoperative worsening of the cognitive status at one-year follow-up. Secondary endpoints aimed to describe postoperative disabilities and complications, to investigate possible risk factors for cognitive worsening, and to measure the role of anesthesia in cognitive changes.

RESULTS

We recorded an increased rate of pathological 6CIT values during the hospitalization period, rising from 39.47% to 55.26% (McNemar test, P=0.007), and this rate was still increased at 55.56% (P=0.021) one year after discharge. Anesthesia did not show any significant harmful effect on cognitive status. The preoperative hemoglobin value seems to be a risk factor for cognitive status and one-year mortality.

CONCLUSIONS

Elderly patients had a significantly worse 6CIT value after planned surgery, which may derive in part from age and in part from hospitalization. It is difficult to determine if general anesthesia alone has no harmful effects on cognitive performance in patients at discharge and one year later. Further data are necessary.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

BACKGROUND

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients.

METHODS

We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded.

RESULTS

PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p < 0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p < 0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p = 0.019; stage III: 4.4, p = 0.002; stage IV: 4.8, p = 0.002), age (OR: 1.0; p < 0.001), and ASA grade >2 (OR: 1.4; p = 0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p = 0.050).

CONCLUSION

The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) scoring system in predicting postoperative mortality in patients undergoing emergency laparotomy: A retrospective study

Background and Aims

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy.

Methods

This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients.

Results

The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively.

Conclusion

Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Long-Term Results of Thoracofemoral Bypass in the Initial Treatment of Juxtarenal Total Aortic Occlusion

BACKGROUND

Thoracofemoral bypass has been applied mostly secondary to previous procedures in the treatment of aortoiliac occlusive disease. However, its application as an initial treatment is less common, and long-term outcomes remain uncertain. The aim of this analysis was to review the 16-year experience and long-term outcomes of 31 consecutive patients who underwent thoracofemoral bypass as the primary procedure.

METHODS

All patients who underwent thoracofemoral bypass for severe aortoiliac occlusive disease between 2005 and 2021 were retrospectively analyzed. The occlusion and calcified plaques of the abdominal aorta at the renal level were common characteristics of all patients. The patients were divided into 2 groups: severe claudication group (Rutherford III group) and chronic limb-threatening ischemia group (Rutherford IV-V). Chi-square test or Fisher's exact test was used to compare categorical variables between the groups, and t-test or Mann-Whitney U-tests were used to compare continuous variables according to their distributions. The Kaplan-Meier curve was used to depict the time-to-event data.

RESULTS

Thirty-one patients [age: 62 (56-67.5); male: 87%] underwent thoracofemoral bypass. Among the 31 patients, 21 (67.7%) belonged to the severe claudication group (Rutherford III), while 10 (32.3%) were in the chronic limb-threatening ischemia (Rutherford IV-V). Twenty-two patients (83.8%) remained asymptomatic after thoracofemoral bypass. The mean follow-up duration was 79 ± 32 months. The 30-day mortality rate was 3.2% (n = 1). Major complications were observed in 9.6% of patients (n = 3; respiratory: 6.4%, retroperitoneal hematoma: 3.2%). No significant difference was found between the claudication and chronic limb-threatening ischemia groups regarding major complications (3.2% vs. 6.4%, P = NS). Minor complications occurred in 41.9% of patients, including pleural effusion 9.6% (n = 3), acute kidney injury 9.6% (n = 3), gastrointestinal bleeding 3.2% (n = 1), paralytic ileus 6.4% (n = 2), and superficial skin infection 12.9% (n = 4). The rate of postoperative superficial skin infection was higher in the chronic limb-threatening ischemia group compared to the claudication group (4 [40%] vs. 0 [0%], P: 0.007). The univariable Cox regression analysis revealed that hypertension and diabetes mellitus were not related to primary patency of the thoracofemoral bypass graft. The 5-year Kaplan-Meier estimated primary patency for the entire study was 96% ± 7% (95% confidence interval [CI]: 88.6-100), and the secondary patency was 96.3% ± 6% (95% CI: 89.4-100). The 5-year Kaplan-Meier estimated survival rate after thoracofemoral bypass was 93.4% ± 3 (95% CI: 91-100).

CONCLUSIONS

We demonstrated in this study that thoracofemoral bypass can yield good outcomes when preferred as the initial treatment in selected patients with juxtarenal total aortic occlusion. Despite being a complex surgical technique, thoracofemoral bypass has shown to have safe, acceptable mortality and morbidity rates, as well as excellent long-term follow-up results in selected patients.

Clinical usefulness of routinely performed drain fluid cultures after pancreaticoduodenectomy. A new ally to predict patients' outcomes?

BACKGROUND

Previous studies showed that bacterial contamination of surgical drains was associated with higher morbidity and mortality following pancreaticoduodenectomy (PD). However, there is still no agreement on the routine use of fluid drainage cultures in the management of patients underwent PD. Therefore, we aimed to clarify the role of surgical drain bacterial contamination in predicting patients' postoperative course.

METHOD

Single-centre study including patients underwent PD at Humanitas Research Hospital (2010-2021). Preoperative, intraoperative and postoperative data were collected. Routinely performed fluid drain cultures on postoperative day (POD) 5 were analyzed and compared among patients throughout the cohort.

RESULTS

A total of 825 patients were analyzed. Bacterial contamination of surgical drains was observed in 420 (50.9 %) patients and it was found to be associated with a higher rate of B/C grade pancreatic fistula (POPF) (P < 0.001), Clavien-Dindo≥3 (P < 0.001), 30-day mortality (P = 0.011), wound infection (P < 0.001), relaparotomies (P = 0.003) and greater length of hospital stay (LOS) (P < 0.001). Also, E. coli surgical drain contamination was demonstrated to double the risk of B/C grade POPF development (OR = 1.628, 95 % IC = 1.009-2.625, P = 0.046). Finally, preoperative biliary drainage (OR = 2.474, 95 % IC = 1.855-3.298, P < 0.001), age ≥75 years old (OR = 1.492, 95 % IC = 1.077-2.067, P = 0.016) and isolated Roux-en-Y pancreaticojejunostomy (OR = 1.639, 95 % IC = 1.229-2.188, P < 0.001) were identified as risk factors for surgical drains bacterial contamination.

CONCLUSION

Bacterial contamination of surgical drains predicts the development of B/C grade POPF and other major complications after PD. Therefore, we suggest the routine use of fluid drain cultures following PD.

Construction of a predictive model for blood transfusion in patients undergoing total hip arthroplasty and identification of clinical heterogeneity

A precise forecast of the need for blood transfusions (BT) in patients undergoing total hip arthroplasty (THA) is a crucial step toward the implementation of precision medicine. To achieve this goal, we utilized supervised machine learning (SML) techniques to establish a predictive model for BT requirements in THA patients. Additionally, we employed unsupervised machine learning (UML) approaches to identify clinical heterogeneity among these patients. In this study, we recruited 224 patients undergoing THA. To identify factors predictive of BT during the perioperative period of THA, we employed LASSO regression and the random forest (RF) algorithm as part of supervised machine learning (SML). Using logistic regression, we developed a predictive model for BT in THA patients. Furthermore, we utilized unsupervised machine learning (UML) techniques to cluster THA patients who required BT based on similar clinical features. The resulting clusters were subsequently visualized and validated. We constructed a predictive model for THA patients who required BT based on six predictive factors: Age, Body Mass Index (BMI), Hemoglobin (HGB), Platelet (PLT), Bleeding Volume, and Urine Volume. Before surgery, 1 h after surgery, 1 day after surgery, and 1 week after surgery, significant differences were observed in HGB and PLT levels between patients who received BT and those who did not. The predictive model achieved an AUC of 0.899. Employing UML, we identified two distinct clusters with significantly heterogeneous clinical characteristics. Age, BMI, PLT, HGB, bleeding volume, and urine volume were found to be independent predictors of BT requirement in THA patients. The predictive model incorporating these six predictors demonstrated excellent predictive performance. Furthermore, employing UML enabled us to classify a heterogeneous cohort of THA patients who received BT in a meaningful and interpretable manner.

Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution

BACKGROUND

Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA.

RESULTS

Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001).

CONCLUSION

The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

The effect of triclosan-coated sutures on the incidence of surgical site infection in laparoscopic sleeve gastrectomy, laparoscopic appendicectomy or laparoscopic cholecystectomy: A multi-centre, double-blind, randomized, intra-individual study

Surgical site infection (SSI) is a common cause of post-operative morbidity. According to the latest report announced by CDC, the SSI accounts for 20% of healthcare-associated infection with a high risk of mortality up to twofold to 11-fold increase with high economic burden for the prolonged hospital stay. Port site infection (PSI) is a subgroup of SSI occurring at the ports of laparoscopy. We tried to determine the efficacy of polyglactin 910 suture coated with triclosan in lowering the rate of PSI in some of the clean-contaminated wound surgeries. This study included 480 individuals eligible for laparoscopic cholecystectomy, appendicectomy or sleeve operations. Polyglactin 910 sutures coated with triclosan were used in one port site incision while polyglactin 910 sutures were used in the other port sites incisions. In patients who underwent laparoscopic cholecystectomy and appendicectomy, the incidence of PSI was significantly lower in the triclosan-coated sutures. In sleeve gastrectomy patients, although a lower number of triclosan-coated sutures developed PSI, there was no statistically significant difference between triclosan and non-triclosan-coated sutures. This study showed that using sutures coated with antiseptics like triclosan has clinical benefits to prevent SSIs in most of the laparoscopic surgeries.

The effective dose of remimazolam in adult gastroscopy

OBJECTIVES

The objectives of this study were to explore the median effective dose (ED50) and the dose required for successful anesthesia in 95% of the patients (ED95) of remimazolam for intravenous anesthesia in adult outpatients undergoing gastroscopy.

METHODS

This pilot study was conducted in patients scheduled to undergo painless gastroscopy at the authors' hospital between March 15, 2022 and March 25, 2022. The ED of remimazolam was determined using the modified Dixon sequential method, using an initial induction dose of 0.2 mg/kg. With successful or failed anesthesia, the remimazolam dose was decreased or increased by 0.05 mg/kg for the next patient, respectively.

RESULTS

Twenty-two patients (43.6 ± 10.5 years of age) were enrolled. During gastroscopy, the remimazolam induction dose was 19.93 ± 2.96 mg (0.2-0.45 mg/kg). Eighteen patients could complete anesthesia with remimazolam alone, and four patients needed propofol to complete anesthesia. The induction time after the injection of remimazolam was 20.8 ± 8.4 s, the gastroscopy time was 5.1 ± 1.3 min, and the anesthesia recovery time was 17.5 ± 5.6 min. The ED50 and the ED95 of remimazolam were 0.362 mg/kg (95% confidence interval [CI]: 0.313-0.455 mg/kg) and 0.464 mg/kg (95% CI: 0.403-2.242 mg/kg), respectively. The vital signs of all patients remained within the predefined acceptable limits. No patients required antagonist rescue.

CONCLUSION

The ED50 and ED95 of remimazolam for adult gastroscopy were 0.362 mg/kg and 0.464 mg/kg, respectively. Additional anesthetics might be required during gastroscopy in some patients.

TRIAL REGISTRATION

The trial was registered. The number is ChiCTR2200057446.

Prolonged application time effects on universal adhesives in non-carious cervical lesions: An 18-month split mouth randomized clinical trial

OBJECTIVE

This double-blind, split mouth randomized clinical trial aimed to assess the clinical performance of Clearfil Universal Bond Quick (CBUq) universal adhesive under different application times (no waiting and waiting) compared to Clearfil SE Bond adhesive in non-carious cervical lesions (NCCLs) over 18 months.

METHODS

One hundred and eighty-three restorations were distributed randomly into three groups based on the adhesive system and waiting time: CUBq without waiting time (CUBq-NW), CUBq with a 20 s waiting time (CUBq-W), and CSE with a 20 s waiting time. After placement, restorations were evaluated after 18 months using the International Dental Federation (FDI) and United States Public Health Service (USPHS) criteria. Statistical analyses involved Friedman repeated measures analysis of variance and Wilcoxon tests, with a significance level set at 5 %.

RESULTS

Over the 18-month period, no restorations were lost across the tested groups. Marginal adaptation evaluation indicated minor discrepancies in 21 restorations (8 CUBq-NW, 6 CUBq-W, and 7 CSE). There were no significant differences observed among the three groups following the 18-month clinical assessment (p > 0.05). Only two restorations showed marginal discoloration after 18 months (1 CUBq-NW and 1 CSE).

CONCLUSIONS

The application of Clearfil Universal Bond Quick using either the "waiting" or "no-waiting" technique exhibited excellent clinical results in NCCLs during the 18-month follow-up period, demonstrating comparable performance to Clearfil SE Bond in all assessed outcomes.

CLINICAL SIGNIFICANCE

The findings suggest that the new universal adhesive applied using the no-waiting technique demonstrates promising clinical performance when compared to conventional application methods.

TRIAL REGISTRATION

ClinicalTrials.gov identifer RBR-69p7mpr.

Endoscopic retrograde cholangiopancreatography utilisation and outcomes in the first advanced endoscopy centre in Palestine at Al-Ahli Hospital: a retrospective cohort study

OBJECTIVE

To evaluate the utilisation and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) procedures, success rates, incidence and risk factors for procedural-related complications in a single centre-based study.

STUDY DESIGN

Retrospective cohort study.

SETTING

First advanced tertiary endoscopy centre in Palestine.

PARTICIPANTS

A total of 1909 procedures on 1303 patients were included in the analysis: females were 57.9% of the cases (n=755), 1225 patients (94%) were from West Bank and Jerusalem and 78 (6%) were from Gaza Strip. All patients who underwent ERCP throughout the period from December 2017 to September 2022 were selected to participate in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes of interest in our analysis were success rates, procedural outcomes and post- procedural complications including pancreatitis, bleeding and others. Two multivariate logistic regression models were performed to calculate the risk of post-ERCP complications and post-ERCP pancreatitis (PEP) in patients with certain risk factors like demographic factors, procedural techniques' variation, pancreatic duct manipulations and others. We also discussed the management of the failed procedures.

RESULTS

The overall complication rate was 5%, including PEP (n=43, 2.3%), infection/cholangitis (n=20, 1%), bleeding (n=9, 0.5%) and perforation (n=7, 0.4%). The mortality rate was 0.6% (n=11). Risk factors for adverse events included pancreatic duct cannulation and PEP (p<0.001, OR=3.64). Additionally, younger patients (≤45) were found to carry a higher risk for PEP when compared with older patients (≥65) (p=0.023, OR=2.84). In comparison with sphincterotomy, the double-wire technique was associated with a higher risk of complications (p=0.033, OR=2.29).

CONCLUSIONS

We summarised the utilisation and outcomes of ERCP among the Palestinian population in the first advanced centre in Palestine. Cannulation success rates are similar to the established standards and are acceptable compared with other centres worldwide. Perioperative complication rates of ERCP remain infrequent, and death is quite unusual and thus considered a safe procedure.

Liberal intraoperative fluid management leads to increased complication rates in geriatric patients with hip fracture

PURPOSE

Fractures of the proximal femur in geriatric patients are life-changing and life-threatening events. Previous research has identified fluid volume as an independent factor contributing to trauma patients' complications. Therefore, we aimed to investigate the impact of intraoperative fluid volume on outcomes in geriatric patients undergoing hip fracture surgery.

METHODS

We conducted a retrospective single-center study with data from the hospital information systems. Our study included patients aged 70 years or older who had sustained a proximal femur fracture. We excluded patients with pathologic, periprosthetic, or peri-implant fractures and those with missing data. Based on the fluids given, we divided patients into high-volume and low-volume groups.

RESULTS

Patients with a higher American Society of Anesthesiologists (ASA) grade and more comorbidities were more likely to receive more than 1500 ml of fluids. We observed significant differences in anesthesiologic management between the two groups, with a higher rate of invasive blood pressure management (IBP) and central venous catheter usage in the high-volume group. High-volume therapy was associated with a higher rate of complications (69.7% vs. 43.6%, p < 0.01), a higher transfusion rate (odds ratio 1.91 [1.26-2.91]), and an increased likelihood of patients being transferred to an intensive care unit (17.1% vs. 6.4%, p = 0.009). These findings were confirmed after adjusting for ASA grade, age, sex, type of fracture, Identification-of-Seniors-At-Risk (ISAR) score, and intraoperative blood loss.

CONCLUSIONS

Our study suggests that intraoperative fluid volume is a significant factor that impacts the outcome of hip fracture surgery in geriatric patients. High-volume therapy was associated with increased complications.

Risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma: A systematic review and meta-analysis

BACKGROUND

To further define the risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma.

METHODS

Records from five English databases and four Chinese databases. Odds ratios (OR) and 95 % confidence intervals (CI) were used to indicate the risk of inclusion of risk factors. The non-closure stoma rate used the risk difference (RD) and 95 % CI. Risk factors were evaluated for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age ≥60 years[OR:1.57, 95%CI(1.44,1.72)], Tumor IV stage[OR:4.21, 95%CI(2.29,7.74)], American Society of Anesthesiologists (ASA)≥3[OR:1.48, 95%CI(1.33,1.65)], Neoadjuvant chemoradiotherapy[OR:1.41, 95%CI(1.09,1.82)],Open surgery[OR:1.45, 95%CI(1.09,1.93)], Postoperative chemotherapy[OR:1.37, 95%CI(1.03,1.82)], Anastomotic leakage[OR:4.61, 95%CI(2.86, 7.44)], Local recurrence[OR:7.16, 95%CI(4.70, 10.91)]. The rate of non-closure stoma after anterior resection for rectal cancer was: 0.20, 95 % CI (0.17, 0.23). The quality of evidence for stage IV tumors and anastomotic leakage was moderate, and other risk factors were low to very low.

CONCLUSIONS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age≥60 years, Tumor IV stage, ASA≥3, Neoadjuvant chemoradiotherapy, Open surgery, Postoperative chemotherapy, Anastomotic leakage, Local recurrence, and one in five anterior resection patients with a temporary stoma fails to close.

Short- and long-term outcomes of Roux-en-Y and Billroth II with Braun reconstruction in total laparoscopic distal gastrectomy: a retrospective analysis

BACKGROUND

The controversy surrounding Roux-en-Y (R-Y) and Billroth II with Braun (BII + B) reconstruction as an anti-bile reflux procedure after distal gastrectomy has persisted. Recent studies have demonstrated their efficacy, but the long-term outcomes and postoperative quality of life (QoL) among patients have yet to be evaluated. Therefore, we compared the short-term and long-term outcomes of the two procedures as well as QoL.

METHODS

The clinical data of 151 patients who underwent total laparoscopic distal gastrectomy (TLDG) at the Gastrointestinal Surgery Department of the Second Hospital of Fujian Medical University from January 2016 to December 2019 were retrospectively analyzed. Of these, 57 cases with Roux-en-Y procedure (R-Y group) and 94 cases with Billroth II with Braun procedure were included (BII + B group). Operative and postoperative conditions, early and late complications, endoscopic outcomes at year 1 and year 3 after surgery, nutritional indicators, and quality of life scores at year 3 postoperatively were compared between the two groups.

RESULTS

The R-Y group recorded a significantly longer operative time (194.65 ± 21.52 vs. 183.88 ± 18.02 min) and anastomotic time (36.96 ± 2.43 vs. 27.97 ± 3.74 min) compared to the BII + B group (p < 0.05). However, no other significant differences were observed in terms of perioperative variables, including blood loss (p > 0.05). Both groups showed comparable rates of early and late complications. Endoscopic findings indicated similar food residuals at years 1 and 3 post-surgery for both groups. The R-Y group had a lower occurrence of residual gastritis and bile reflux at year 1 and year 3 after surgery, with a statistically significant difference (p < 0.001). Reflux esophagitis was not significantly different between the R-Y and BII + B groups in year 1 after surgery (p = 0.820), but the R-Y group had a lower incidence than the BII + B group in year 3 after surgery (p = 0.023). Nutritional outcomes at 3 years after surgery did not differ significantly between the two groups (p > 0.05). Quality of life scores measured by the QLQ-C30 scale were not significantly different between the two groups. However, on the QLQ-STO22 scale, the reflux score was significantly lower in the R-Y group than in the BII + B group (0 [0, 0] vs. 5.56 [0, 11.11]) (p = 0.003). The rest of the scores were not significantly different (p > 0.05).

CONCLUSION

Both R-Y and B II + B reconstructions are equally safe and efficient for TLDG. Nevertheless, the R-Y reconstruction reduces the incidence of residual gastritis, bile reflux, and reflux esophagitis, as well as postoperative reflux symptoms, and provides a better quality of life for patients. R-Y reconstruction is superior to BII + B reconstruction for TLDG.

Impact of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children: a prospective, randomized controlled trial

Objective

To compare the efficacy of intravenous administration of nalbuphine at different time points for postoperative analgesia and sedation in adenotonsillectomized children.

Methods

Patients with obstructive sleep apnea syndrome scheduled for adenotonsillectomy were randomly divided into group A (patients received intravenous nalbuphine 0.2 mg/kg before anesthesia induction), group B (patients received intravenous nalbuphine 0.2 mg/kg 10 min before the end of surgery), and group C (patients did not receive nalbuphine injection). The time points for measuring outcomes were before anesthesia induction (T0), extubation (T1), and 0, 15, 30, or 45 min in the postanesthesia care unit (PACU) (T2-T5, respectively).

Results

There were 40 patients in group A, 41 patients in group B and 39 patients in group C. Patients in group B had significantly lower FLACC (Face, Legs, Activity, Cry, Consolability) pain scores at T2-T5 than those in group C (all p<0.05). Patients in group B had higher Ramsay Sedation Score at T2-T4 than those in group C (all p<0.05). The proportion of patients who received remedial analgesia in the PACU in group A (17.5%, p=0.008) and group B (9.8%, p<0.001) was significantly lower than that in group C (46.2%).

Conclusion

Intravenous administration of nalbuphine 10 min before the end of adenotonsillectomy in children could decrease pain intensity and increase sedation levels during the recovery period with the reduction of remedial analgesia in the PACU.Trial registration number ChiCTR2200060118.

Fibula flap in upper extremity segmental/critical size bone defects fixed with locking plates. Single-institution observational cohort

INTRODUCTION

Management of bone defects in the upper extremity can vary depending on the size and location of the defect. Large defects may require complex reconstruction techniques. Vascularized bone grafts, mainly free vascularized fibula flap (FVFF), have many advantages in the treatment of bone or osteocutaneous defects. However, complications such as graft fracture are the most common, with a free fibula flap for bone defects in the upper extremity. This study aimed to describe the results and complications associated with the treatment of posttraumatic bone defects in the upper extremity using FVFF. We hypothesized that performing osteosynthesis using locking plates would prevent or reduce the fracture of the fibula flap MATERIALS AND METHODS: This was a retrospective single-centre cohort study. Patients with segmental bone defects caused by trauma who underwent reconstructive surgery with FVFF fixed with locking compression plates (LCP) between January 2014 and 2022 were included. Demographic variables and preoperative data, such as bone defect, location, and time until reconstruction, were collected. Bone defects were classified according to the Testworth classification. Intraoperative variables included the length of the FVFF, type of graft (osteocutaneous or not), type and technique of arterial and venous sutures, number of veins used as output flow, and the osteosynthesis technique used.

RESULTS

Ten patients were included (six humerus, three ulna, and one radius). All patients had critical-size bone defects, and nine patients had a history of infection. In 9 of 10 patients, bone fixation was performed with a bridge LCP and in one patient with two LCP plates. In eight cases, the FVFF was osteocutaneous. All the patients showed bone healing at the end of the follow-up period. There was one early complication, donor site wound dehiscence, and two long-term complications (proximal radioulnar synostosis and soft-tissue defect).

CONCLUSION

A high rate of bone union with a low rate of complications can be obtained with an FVFF in upper extremity segmental/critical-size bone defects. Rigid fixation with locking plates avoids stress fractures of the grafts, mainly in humeral reconstruction. However, in these cases, a bridge plate should be used.

A 5-year experience with midline catheters in the management of major head and neck surgery patients

BACKGROUND

In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development.

METHODS

Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications.

RESULTS

A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications.

CONCLUSIONS

MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.

Pituitary surgery outcome in patients 75 years and older: a retrospective study

BACKGROUND

As the population ages, the number of elderly patients with an indication for pituitary surgery is rising. Information on the outcome of patients aged over 75 is limited. This study reports a large series assessing the feasibility of surgical resection in this specific age range, focusing on surgical complications and postoperative results.

METHODS

A retrospective cohort study of patients with pituitary adenomas and Rathke's cleft cysts was conducted. All patients were aged 75 years or over and treated by a single expert neurosurgical team. A control population included 2379 younger adult patients operated by the same surgeons during the same period.

RESULTS

Between 2008 and 2022, 155 patients underwent surgery. Indication was based on vision impairment in most patients (79%). Median follow-up was 13 months (range: 3-96). The first surgery was performed with an endoscopic transsellar approach, an extended endonasal transtuberculum approach and a microscopic transcranial approach in 96%, 3%, and 1% of patients, respectively. Single surgery was sufficient to obtain volume control in 97% of patients. From Kaplan-Meier estimates, 2-year and 5-year disease control with a single surgery were 97.3% and 86.2%, respectively. Resection higher than 80% was achieved in 77% of patients. No vision worsening occurred. In acromegaly and Cushing's disease, endocrine remission was obtained in 90% of non-invasive adenomas. Surgical complications were noted in 5% of patients, with 30-day mortality, hematoma, cerebrospinal fluid leak, meningitis, and epistaxis occurring in 0.6%, 0.6%, 1.9%, 0.6%, and 1.3% respectively. New endocrine anterior deficits occurred in only 5%, while no persistent diabetes insipidus was noted. Compared with younger patients, the complication rate was not statistically different.

CONCLUSIONS

Surgery beyond the age of 75, mainly relying on an endoscopic endonasal transsellar approach, is effective and safe, provided that patients are managed in tertiary centers.

Randomized trial of ketamine masked by surgical anesthesia in patients with depression

Ketamine may have antidepressant properties, but its acute psychoactive effects complicate successful masking in placebo-controlled trials. We present a single-center, parallel-arm, triple-masked, randomized, placebo-controlled trial assessing the antidepressant efficacy of intravenous ketamine masked by surgical anesthesia (ClinicalTrials.gov, NCT03861988). Forty adult patients with major depressive disorder who were scheduled for routine surgery were randomized to a single infusion of ketamine (0.5 mg/kg) or placebo (saline) during usual anesthesia. All participants, investigators, and direct patient care staff were masked to treatment allocation. The primary outcome was depression severity measured by the Montgomery-Åsberg Depression Rating Scale (MADRS) at 1, 2, and 3 days post-infusion. After all follow-up visits, participants were asked to guess which intervention they received. A mixed-effects model showed no evidence of effect of treatment assignment on the primary outcome (-5.82, 95% CI -13.3 to 1.64, p=0.13). 36.8% of participants guessed their treatment assignment correctly; both groups allocated their guesses in similar proportions. In conclusion, a single dose of intravenous ketamine delivered during surgical anesthesia had no greater effect than placebo in acutely reducing the severity of depressive symptoms in adults with major depressive disorder. This trial successfully masked treatment allocation in moderate-to-severely depressed patients using surgical anesthesia. Although this masking strategy is impractical for most placebo-controlled trials, future studies of novel antidepressants with acute psychoactive effects should make efforts to fully mask treatment assignment in order to minimize subject-expectancy bias.

Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction

BACKGROUND

To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d).

METHODS

Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula.

RESULTS

Median values of l2 , l1 , and b were 3.0, 6.0, and 6.0 cm, respectively. When l2  = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1 /l2  < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation.

CONCLUSION

Careful patient selection, adequate proximal SP, and l2  = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.

The ASA Classification System as a Predictive Factor to Stay at the Virtual Hybrid Care Hotel

INTRODUCTION

The Care Hotel is a virtual hybrid care model for postoperative patients after low-risk procedures which allow recovery in an outpatient environment. This study aimed to analyze if the American Society of Anesthesiologists Physical Status (ASA PS) Classification System can be used as a predictive factor for staying at Mayo Clinic's Care Hotel.

METHODS

This retrospective cohort study was conducted between July 23, 2020, and June 4, 2021, at Mayo Clinic in Florida, a 306-bed community academic hospital. ASA PS Class and post-procedure care setting (Care Hotel vs inpatient ward) were collected. Patients were classified into two ASA PS groups (ASA PS Classes 1-2 and 3-4). Pearson's Chi-square test was used to determine if the ASA PS Class and having stayed or not at the Care Hotel were independent and an Odds Ratio (OR) calculated.

RESULTS

Out of 392 surgical and procedural patients, 272 (69.39%) chose the Care Hotel and 120 (30.61%) chose the inpatient ward. There was a statistically significant association between ASA PS Class and staying at the Care Hotel, P < .01. The OR of preferring to stay at the Care Hotel in patients with ASA PS Class 1-2 vs ASA PC Class 3-4 was 1.91 (P = .0041, 95% CI: 1.229-2.982).

CONCLUSION

Patients with ASA PS Classes 1-2 are almost twice as likely to elect to stay at the Care Hotel compared to those with ASA PS Classes 3-4. This finding may help care teams focus their Care hotel recruitment efforts.

Efficacy and safety of flurbiprofen‑axetil combined with nalbuphine pretreatment on remifentanil‑induced postoperative hyperalgesia: A randomized clinical trial

Remifentanil-induced hyperalgesia (RIH) is a common and complicated issue in patients undergoing laparoscopic cholecystectomy (LC), which significantly reduces patient satisfaction. The present trial was designed to clarify the individual and combined effects of flurbiprofen-axetil and nalbuphine on remifentanil-induced hyperalgesia. This randomized double-blind clinical trial included 120 adult patients who underwent LC at The Second People's Hospital of Wuhu. The individuals were randomized into a flurbiprofen-axetil group (F group), nalbuphine group (N group), flurbiprofen-axetil combined with nalbuphine group (FN group) and saline group (S group). The four groups were given flurbiprofen-axetil (50 mg, iv.), nalbuphine (0.1 mg/kg, iv.), flurbiprofen-axetil (50 mg, iv.) combined with nalbuphine (0.1 mg/kg, iv.) or normal saline respectively prior to skin incision. The primary outcome was the postoperative mechanical pain thresholds at the inner forearm and peri-incisional area. The secondary outcomes were the visual analog scale (VAS) and Ramsay sedation scale at 0.5, 1, 4 and 24 h after surgery, and any other adverse events. The pain threshold of the medial forearm in the FN group did not differ from that in the F and N groups at 24 h after surgery (P=0.310 and P=0.910, respectively). However, the pain threshold around the incision in FN group was significantly lower than that in F and N groups 24 h after surgery (P=0.001). The VAS of the F group, N group and FN group were all significantly lower than that in the S group at 0.5, 1 and 24 h after surgery (P<0.001). No significant differences were observed in the incidence of adverse events between the four groups. Single flurbiprofen-axetil and single nalbuphine effectively prevented RIH 24 h after surgery in LC. The combination of the two analgesic drugs, with different mechanisms of action, was not superior to single therapy. The present study was registered with the Chinese Clinical Trial Registry (registration no. ChiCTR2100045347).

Carotid Endarterectomy in the Very Elderly: Short-, Medium-, and Long-Term Outcomes

Purpose

: Carotid endarterectomy (CEA) has an established effect on stroke-free survival in patients with carotid artery stenosis. Most landmark trials excluded patients ≥80 years of age due to their perceived high risk and uncertainty regarding the benefits of CEA. Despite the ongoing global increase in life expectancy, guidelines have not changed. The current study aimed to assess CEA outcomes in patients ≥80 years of age.

Materials and Methods

: Data from patients ≥80 years of age, who underwent CEA between April 2016 and April 2022, were collected. Demographic information, comorbidities, surgical details, operative details, outcomes, and post-CEA survival were reviewed, and long-term data up to April 2023 were collected.

Results

: Over the 6-year study period, 258 CEA procedures were recorded, of which 70 (27.1%) were performed in patients ≥80 years of age; the mean age was 84 years (range, 80-96 years), 47 (67.1%) were males, and 69 (98.6%) were symptomatic. Twenty-three (32.9%) patients were American Society of Anesthesiologists (ASA) grade 2, and 47 (67.1%) were grade 3. The 30-day stroke and mortality rates were 4.3% and 1.4%, respectively. At 1, 3, and 5 years, the cumulative freedom-from-stroke rates were 95.7%, 92.9%, and 91.4%, respectively, and the cumulative survival rates were 94.3%, 75.7%, and 61.4%, respectively. No risk factors affected early or late stroke or early mortality rates. Patients with ASA grade 3 had significantly lower cumulative survival than those with grade 2 (HR, 5.29; 95% CI, 1.590-17.603; P<0.01).

Conclusion

: CEA was safe and effective in average-risk, elderly patients. Higher risk patients (i.e., ASA 3) showed no increased 30-day risk for stroke or mortality but exhibited significantly worse long-term survival. Hence, careful consideration of the benefits before performing CEA is crucial.

Comparison of Surgical Risk Scores in a European Cohort of Patients with Advanced Chronic Liver Disease

Patients with advanced chronic liver disease (ACLD) or cirrhosis undergoing surgery have an increased risk of morbidity and mortality in contrast to the general population. This is a retrospective, observational study to evaluate the predictive capacity of surgical risk scores in European patients with ACLD. Cirrhosis was defined by the presence of thrombocytopenia with <150,000/uL and splenomegaly, and AST-to-Platelet Ratio Index >2, a nodular liver edge seen via ultrasound, transient elastography of >15 kPa, and/or signs of portal hypertension. We assessed variables related to 90-day mortality and the discrimination and calibration of current surgical scores (Child-Pugh, MELD-Na, MRS, NSQIP, and VOCAL-Penn). Only patients with ACLD and major surgeries included in VOCAL-Penn were considered (n = 512). The mortality rate at 90 days after surgery was 9.8%. Baseline disparities between the H. Mar and VOCAL-Penn cohorts were identified. Etiology, obesity, and platelet count were not associated with mortality. The VOCAL-Penn showed the best discrimination (C-statistic90D = 0.876) and overall predictive capacity (Brier90D = 0.054), but calibration was not excellent in our cohort. VOCAL-Penn was suboptimal in patients with diabetes (C-statistic30D = 0.770), without signs of portal hypertension (C-statistic30D = 0.555), or with abdominal wall (C-statistic30D = 0.608) or urgent (C-statistic180D = 0.692) surgeries. Our European cohort has shown a mortality rate after surgery similar to those described in American studies. However, some variables included in the VOCAL-Penn score were not associated with mortality, and VOCAL-Penn's discriminative ability decreases in patients with diabetes, without signs of portal hypertension, and with abdominal wall or urgent surgeries. These results should be validated in larger multicenter and prospective studies.

Risk prediction models for postoperative delirium in elderly patients with hip fracture: a systematic review

Objectives

To systematically evaluate the risk prediction models for postoperative delirium in older adult hip fracture patients.

Methods

Risk prediction models for postoperative delirium in older adult hip fracture patients were collected from the Cochrane Library, PubMed, Web of Science, and Ovid via the internet, covering studies from the establishment of the databases to March 15, 2023. Two researchers independently screened the literature, extracted data, and used Stata 13.0 for meta-analysis of predictive factors and the Prediction Model Risk of Bias Assessment Tool (PROBAST) to evaluate the risk prediction models for postoperative delirium in older adult hip fracture patients, evaluated the predictive performance.

Results

This analysis included eight studies. Six studies used internal validation to assess the predictive models, while one combined both internal and external validation. The Area Under Curve (AUC) for the models ranged from 0.67 to 0.79. The most common predictors were preoperative dementia or dementia history (OR = 3.123, 95% CI 2.108-4.626, p < 0.001), American Society of Anesthesiologists (ASA) classification (OR = 2.343, 95% CI 1.146-4.789, p < 0.05), and age (OR = 1.615, 95% CI 1.387-1.880, p < 0.001). This meta-analysis shows that these were independent risk factors for postoperative delirium in older adult patients with hip fracture.

Conclusion

Research on the risk prediction models for postoperative delirium in older adult hip fracture patients is still in the developmental stage. The predictive performance of some of the established models achieve expectation and the applicable risk of all models is low, but there are also problems such as high risk of bias and lack of external validation. Medical professionals should select existing models and validate and optimize them with large samples from multiple centers according to their actual situation. It is more recommended to carry out a large sample of prospective studies to build prediction models.

Systematic review registration

The protocol for this systematic review was published in the International Prospective Register of Systematic Reviews (PROSPERO) under the registered number CRD42022365258.

Effectiveness and safety of an atropine/midazolam and target controlled infusion propofol-based moderate sedation protocol during percutaneous endoscopic transgastric jejunostomy procedures in Parkinson's disease: a real-life retrospective observational study

Patients with Parkinson's disease (PD), often elderly with various comorbidities, may require a continuous intestinal infusion of carbidopa/levodopa gel by the placement of a percutaneous endoscopic gastrostomy (PEG) with a jejunal tube (PEG-J) to improve their motor outcome and quality of life. However, it is unclear what is the best procedural sedation protocol for PEG-J procedures. Fifty patients with PD and indication for PEG-J procedure (implantation, replacement, removal) underwent, from 2017 to 2022, a sedation protocol characterized by premedication with atropine (0.01 mg/Kg i.v.), midazolam (0.015-0.03 mg/Kg i.v.) and induction with bolus propofol (0.5-1 mg/Kg i.v.) as well as, finally, sedation with continuous infusion propofol (2-5 mg/Kg/h i.v.) by Target Controlled Infusion (TCI) technique. Ninety-eight per cent of patients experienced no intraprocedural or peri-procedural adverse events. All the procedures were technically successful. A good discharge time was recorded. The vital parameters recorded during the procedure did not vary significantly. A PEG-J procedure conducted within 30 min showed a significant advantage over end-tidal carbon dioxide (EtCO2). Indeed, the latter showed some predictive behavior (OR: 1.318, 95% CI 1.075-1.615, p = 0.008). In the real world, this sedation protocol showed a good safety and effectiveness profile, even with reduced doses of midazolam and a TCI propofol technique in moderate sedation.

Prediction of American Society of Anesthesiologists Physical Status Classification from preoperative clinical text narratives using natural language processing

BACKGROUND

Electronic health records (EHR) contain large volumes of unstructured free-form text notes that richly describe a patient's health and medical comorbidities. It is unclear if perioperative risk stratification can be performed directly from these notes without manual data extraction. We conduct a feasibility study using natural language processing (NLP) to predict the American Society of Anesthesiologists Physical Status Classification (ASA-PS) as a surrogate measure for perioperative risk. We explore prediction performance using four different model types and compare the use of different note sections versus the whole note. We use Shapley values to explain model predictions and analyze disagreement between model and human anesthesiologist predictions.

METHODS

Single-center retrospective cohort analysis of EHR notes from patients undergoing procedures with anesthesia care spanning all procedural specialties during a 5 year period who were not assigned ASA VI and also had a preoperative evaluation note filed within 90 days prior to the procedure. NLP models were trained for each combination of 4 models and 8 text snippets from notes. Model performance was compared using area under the receiver operating characteristic curve (AUROC) and area under the precision recall curve (AUPRC). Shapley values were used to explain model predictions. Error analysis and model explanation using Shapley values was conducted for the best performing model.

RESULTS

Final dataset includes 38,566 patients undergoing 61,503 procedures with anesthesia care. Prevalence of ASA-PS was 8.81% for ASA I, 31.4% for ASA II, 43.25% for ASA III, and 16.54% for ASA IV-V. The best performing models were the BioClinicalBERT model on the truncated note task (macro-average AUROC 0.845) and the fastText model on the full note task (macro-average AUROC 0.865). Shapley values reveal human-interpretable model predictions. Error analysis reveals that some original ASA-PS assignments may be incorrect and the model is making a reasonable prediction in these cases.

CONCLUSIONS

Text classification models can accurately predict a patient's illness severity using only free-form text descriptions of patients without any manual data extraction. They can be an additional patient safety tool in the perioperative setting and reduce manual chart review for medical billing. Shapley feature attributions produce explanations that logically support model predictions and are understandable to clinicians.

The surgical Apgar score predicts postoperative complications and the survival in lung cancer patients

PURPOSE

The surgical Apgar score (SAS)-calculated using the intraoperative variables estimated blood loss, lowest heart rate, and lowest mean systolic pressure-is associated with mortality in cancer surgery. We investigated the utility of the SAS in patients with lung cancer undergoing surgery.

METHODS

We retrospectively analyzed the data of 691 patients who underwent surgery for primary lung cancer between 2015 and 2019 in a single institute and analyzed the impact of the SAS.

RESULTS

Of the 691 patients, 138 (20%), 57 (8.2%), and 7 (1.0%) had postoperative complications of all grades, grades ≥ III, and grade V, respectively, according to the Clavien-Dindo classification. The C-index for postoperative complications of grades ≥ III was 0.605. A lower score (0-5 points) (odds ratio 3.09 against 8-10 points, P = 0.04) and a lower percentage of vital capacity (odds ratio 0.97, P = 0.04) were independent negative risk factors for major postoperative complications. Patients with a lower score (0-5 points) had poor 5-year overall and cancer-specific survival rates (60.1% and 72.3%, respectively; P < 0.05 for both).

CONCLUSIONS

The surgical Apgar score predicted postoperative complications and the long-term survival. Surgeons may improve surgical results using the SAS.