The SingHealth Perioperative and Anesthesia Subject Area Registry (PASAR), a large-scale perioperative data mart and registry

BACKGROUND

To enhance perioperative outcomes, a perioperative registry that integrates high-quality real-world data throughout the perioperative period is essential. Singapore General Hospital established the Perioperative and Anesthesia Subject Area Registry (PASAR) to unify data from the preoperative, intraoperative, and postoperative stages. This study presents the methodology employed to create this database.

METHODS

Since 2016, data from surgical patients have been collected from the hospital electronic medical record systems, de-identified, and stored securely in compliance with privacy and data protection laws. As a representative sample, data from initiation in 2016 to December 2022 were collected.

RESULTS

As of December 2022, PASAR data comprise 26 tables, encompassing 153,312 patient admissions and 168,977 operation sessions. For this period, the median age of the patients was 60.0 years, sex distribution was balanced, and the majority were Chinese. Hypertension and cardiovascular comorbidities were also prevalent. Information including operation type and time, intensive care unit (ICU) length of stay, and 30-day and 1-year mortality rates were collected. Emergency surgeries resulted in longer ICU stays, but shorter operation times than elective surgeries.

CONCLUSIONS

The PASAR provides a comprehensive and automated approach to gathering high-quality perioperative patient data.

The Role of Contrast-Enhanced Mammography After Cryoablation of Breast Cancer

Image-guided cryoablation is an emerging therapeutic technique for the treatment of breast cancer and is a treatment strategy that is an effective alternate to surgery in select patients. Tumor features impacting the efficacy of cryoablation include size, location in relation to skin, and histology (e.g., extent of intraductal component), underscoring the importance of imaging for staging and workup in this patient population. Contrast-enhanced mammography (CEM) utilization is increasing in both the screening and diagnostic settings and may be useful for follow-up imaging after breast cancer cryoablation, given its high sensitivity for cancer detection and its advantages in terms of PPV, time, cost, eligibility, and accessibility compared with contrast-enhanced MRI. This Clinical Perspective describes the novel use of CEM after breast cancer cryoablation, highlighting the advantages and disadvantages of CEM compared with alternate imaging modalities, expected benign postablation CEM findings, and CEM findings suggestive of residual or recurrent tumor.

Cryoablation for the treatment of breast cancer: immunological implications and future perspectives. Utopia or reality?

Cryoablation is a minimally invasive technique currently employed in breast cancer care, that uses freeze and thaw cycles to treat benign breast lesions, small breast cancers or focal sites of metastatic disease in patients not eligible for surgery. The final goal of this procedure is to destroy breast cancer cells using extreme cold. In addition, several studies have shown that this technique seems to have an enhancing effect on the immune response, especially by increasing the expression of tumor neoantigens specific to tumor cells, which are then attacked and destroyed. Exploiting this effect, cryoablation in combination with immunotherapy could be the key to treating early-stage breast cancers or patients who are unsuitable for surgery. According to some recent studies, there are other potential tools that could be used to enhance the therapeutic effect of cryoablation, such as FE3O4 nanoparticles or the manipulation of aquaporin expression. The aim of this narrative review is to summarize the current evidence regarding the use, indications, advantages and disadvantages of cryoablation in the treatment of breast cancer.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery

OBJECTIVES

Compare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

DESIGN

Retrospective propensity score matched cohort.

METHODS

Patients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts.

RESULTS

After matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 - 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 - 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 - 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 - 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 - 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 - 3.06).

CONCLUSIONS

Active COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population.

LEVEL OF EVIDENCE

III.

The Impact of the COVID-19 Pandemic on Orthopaedic Trauma Surgery in a District General Hospital in the United Kingdom

Introduction The 2020 COVID-19 pandemic led to a national lockdown and a major reorganization of healthcare services in the United Kingdom. The center where the study was done was one of the worst affected hospitals in the United Kingdom at the outset of the pandemic. Our study evaluates the impact of the pandemic and national lockdown on the outcomes for patients undergoing orthopedic trauma surgery. Methods We prospectively identified all patients undergoing orthopedic trauma surgery in the unit from 1st March 2020 to 31st May 2020. We recorded demographics, diagnoses, COVID-19 infection status, length of stay, and mortality. This was compared with a comparative group in the same period in 2018 and 2019. Results There was a significant reduction in the number of orthopedic trauma surgery cases (318) performed in 2020 compared to 2019 (423 cases, p<0.001) and 2018 (444 cases, p<0.001). The mean time from injury to presentation was 3.6 days, with 40 patients (12.6%) presenting more than one week after injury. The 30-day mortality was 8.2%, and the six-month mortality was 15.1%, with both significantly higher than in 2018 (p<0.001) and 2019 (p<0.001). COVID-19 testing was positive in 39% of patients, with 30-day mortality in this group at 37%, rising to a 53% six-month mortality. No patients under the age of 50 years old died. The majority of admissions (51%) were due to falls at home. The second most common mechanism was Do-It-Yourself (DIY) injuries. Road traffic accidents accounted for 2%. Conclusion There were significantly fewer cases of orthopedic trauma surgery during the first wave of the COVID-19 pandemic compared to the same period in previous years. The type of trauma also showed low numbers of high-energy and sporting injuries as a result of the national lockdown. Patients undergoing orthopedic trauma surgery who tested positive for COVID-19 had significantly higher 30-day mortality than those without COVID-19, and this increased mortality persisted to six months post-operatively. However, patients under 50 years old appear to be at low risk of death.

Postoperative outcomes of pediatric patients with perioperative COVID-19 infection: a systematic review and meta-analysis of observational studies

OBJECTIVE

To quantify the risk of adverse postoperative outcomes in pediatric patients with COVID-19 infection.

METHODS

We searched PubMed, Embase, Cochrane Library from December 2019 to 21 April 2023. Observational cohort studies that reported postoperative early mortality and pulmonary complications of pediatric patients with confirmed COVID-19-positive compared with COVID-19-negative were eligible for inclusion. We excluded pediatric patients underwent organ transplantation or cardiac surgery. Reviews, case reports, letters, and editorials were also excluded. We used the Newcastle-Ottawa Scale to assess the methodological quality and risk of bias for each included study. The primary outcome was postoperative early mortality, defined as mortality within 30 days after surgery or during hospitalization. The random-effects model was performed to assess the pooled estimates, which were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

RESULTS

9 studies involving 23,031 pediatric patients were included, and all studies were rated as high quality. Compared with pediatric patients without COVID-19, pediatric patients with COVID-19 showed a significantly increased risk of postoperative pulmonary complications (PPCs) (RR = 4.24; 95% CI 2.08-8.64). No clear evidence was found for differences in postoperative early mortality (RR = 0.84; 95% CI 0.34-2.06), postoperative intensive care unit (ICU) admission (RR = 0.80; 95% CI 0.39-1.68), and length of hospital stay (MD = 0.35, 95% CI -1.81-2.51) between pediatric patients with and without COVID-19.

CONCLUSION

Perioperative COVID-19 infection was strongly associated with increased risk of PPCs, but it did not increase the risk of postoperative early mortality, the rate of postoperative ICU admission, and the length of hospital stay in pediatric patients. Our preplanned sensitivity analyses confirmed the robustness of our study findings.

Safety and factors affecting same-day discharge following mastectomy and immediate alloplastic reconstruction

BACKGROUND AND OBJECTIVES

Patients undergoing breast reconstruction following mastectomy are often admitted overnight. In 2020, our institution implemented a protocol change to discharge clinically stable patients immediately. In this study, we examine the safety of same-day discharge following mastectomy and reconstruction.

METHODS

Our retrospective study included female adults undergoing mastectomy and immediate alloplastic reconstruction from August 2019 to January 2020, before implementation of the same-day discharge protocol, and from March 2020 to September 2021, after the protocol implementation. Independent t-test and chi-square analysis was conducted to examine statistical differences.

RESULTS

Two hundred and eighty-five patients were included. Forty-two patients underwent reconstruction before the protocol change (Group 1) and 243 patients underwent reconstruction after the protocol change (Group 2). Group 2 had a greater percentage of prepectoral implant placement. There was no difference in demographics, complications, readmission, or reoperation. Within Group 2, 157 patients were discharged the same day (Group 2a) and 88 patients required overnight admission (Group 2b). Group 2b had higher body mass index, higher percentage of bilateral mastectomy, and larger mastectomy weights. Despite no differences in complications, Group 2b exhibited higher rates of requiring intravenous antibiotics and reoperation.

CONCLUSIONS

Patients may be safely discharged the same day following mastectomy and alloplastic reconstruction without an increase in complications.

Perioperative Mortality of the COVID-19 Recovered Patient Compared to a Matched Control: A Multicenter Retrospective Cohort Study

BACKGROUND

Surgical procedures performed on patients with recent exposure to COVID-19 infection have been associated with increased mortality risk in previous studies. Accordingly, elective surgery is often delayed after infection. The study aimed to compare 30-day hospital mortality and postoperative complications (acute kidney injury, pulmonary complications) of surgical patients with a previous COVID-19 infection to a matched cohort of patients without known previous COVID-19. The authors hypothesized that COVID-19 exposure would be associated with an increased mortality risk.

METHODS

In this retrospective observational cohort study, patients presenting for elective inpatient surgery across a multicenter cohort of academic and community hospitals from April 2020 to April 2021 who had previously tested positive for COVID-19 were compared to controls who had received at least one previous COVID-19 test but without a known previous COVID-19-positive test. The cases were matched based on anthropometric data, institution, and comorbidities. Further, the outcomes were analyzed stratified by timing of a positive test result in relation to surgery.

RESULTS

Thirty-day mortality occurred in 229 of 4,951 (4.6%) COVID-19-exposed patients and 122 of 4,951 (2.5%) controls. Acute kidney injury was observed in 172 of 1,814 (9.5%) exposed patients and 156 of 1,814 (8.6%) controls. Pulmonary complications were observed in 237 of 1,637 (14%) exposed patients and 164 of 1,637 (10%) controls. COVID-19 exposure was associated with an increased 30-day mortality risk (adjusted odds ratio, 1.63; 95% CI, 1.38 to 1.91) and an increased risk of pulmonary complications (1.60; 1.36 to 1.88), but was not associated with an increased risk of acute kidney injury (1.03; 0.87 to 1.22). Surgery within 2 weeks of infection was associated with a significantly increased risk of mortality and pulmonary complications, but that effect was nonsignificant after 2 weeks.

CONCLUSIONS

Patients with a positive test for COVID-19 before elective surgery early in the pandemic have an elevated risk of perioperative mortality and pulmonary complications but not acute kidney injury as compared to matched controls. The span of time from positive test to time of surgery affected the mortality and pulmonary risk, which subsided after 2 weeks.

EDITOR’S PERSPECTIVE

The global impact of the COVID-19 pandemic on pediatric spinal care: A multi-centric study

Background

The COVID-19 pandemic has affected healthcare worldwide since December 2019. We aimed to identify the effect of the COVID-19 pandemic on outpatient clinic and surgical volumes and peri-operative complications for pediatric spinal deformities patients.

Methods

In this multi-center retrospective study, outpatient visits (in-person and virtual care) and pediatric spine surgeries volumes in four high-volume pediatric spine centers were compared between March and December 2019 and the same period in 2020. Peri-operative complications were collected and compared in the same periods. Descriptive statistics were calculated, and comparative analyses were performed.

Results

During the 2020 study period, the outpatient visit (in-person and virtual care) volume decreased during local lockdown periods by 71% for new patients (p < 0.001) and 53% for returning patients (p = 0.03). Overall, for 2020, there was a 20% reduction in new patients (p = 0.001) and 21% decrease in returning patients (p < 0.001). During the pandemic, there was also 20% less overall surgical volume of adolescent idiopathic scoliosis (AIS) patients undergoing primary posterior spinal fusion, with a 70% reduction during lockdown times (p < 0.001). Complication rate and profile were similar between periods.

Conclusion

There was a significant decrease in outpatient pediatric spine outpatient visits, particularly new patients, which may increase the proportion of pediatric patients with spinal deformities that present late, meeting surgical indication. This, in combination with the reduction in surgical volume of AIS over the first year of the pandemic, could result in an extended waitlist for surgeries during years to come. Complication rate was similar for both periods, suggesting it is safe to continue elective pediatric spine surgery even in a time of a pandemic.

Level of evidence

level IV.

Relationship Between Preoperative Inflammation Ratios Derived From Preoperative Blood Cell Count and Postoperative Pulmonary Complications in Patients Undergoing Lobectomy: A Single-Center Observational Study

OBJECTIVE

Evaluation of the association of inflammatory cell ratios, especially neutrophil-to-lymphocyte ratio (NLR), based on preoperative complete blood counts, with postoperative complications in lobectomy surgery.

DESIGN

This was a retrospective monocentric cohort study.

SETTING

The study was conducted at Foch University Hospital in Suresnes, France.

PARTICIPANTS

Patients having undergone a scheduled lobectomy from January 2018 to September 2021.

INTERVENTIONS

There were no interventions.

MEASUREMENTS AND MAIN RESULTS

The authors studied 208 consecutive patients. Preoperative NLR, monocyte-to-lymphocyte ratio, platelet-to-lymphocyte ratio, systemic inflammation index, systemic inflammation response index, and aggregate inflammation systemic index were calculated. Median and (IQR) of NLR was 2.67 (1.92-3.69). No statistically significant association was observed between any index and the occurrence of at least one major postoperative complication, which occurred in 37% of the patients. Median postoperative length of stay was 7 (5-10) days. None of the ratios was associated with prolonged length of stay (LOS), defined as a LOS above the 75th percentile.

CONCLUSIONS

The results suggested that simple available inflammatory ratios are not useful for the preoperative identification of patients at risk of postoperative major complications in elective lobectomy surgery.

Impact of perioperative SARS-CoV-2 Omicron infection on postoperative complications in liver cancer hepatectomy: A single-center matched study

OBJECTIVES

To explore the effects of perioperative SARS-CoV-2 Omicron infection on postoperative complications in patients with liver cancer.

METHODS

A propensity-matched study was conducted, which included patients with primary liver cancer who underwent hepatectomy from September 01, 2022 to January 20, 2023. Patients who infected SARS-CoV-2 Omicron during the perioperative period (7 days before to 30 days after surgery) were matched 1:1 with noninfected patients. The primary outcomes, which were COVID-19-related major complications and liver resection-specific complications, were analyzed using multivariate logistic regression.

RESULTS

A total of 243 patients were included, with 63 cases of perioperative infections, of which 62 were postoperative infections. The overall 30-day postoperative mortality rate was 1.6% (4/243). Compared to noninfected patients, those with perioperative infections showed no significant difference in the occurrence of adverse postoperative outcomes. However, they had a higher rate of 30-day readmission after surgery (11.1% vs 0%, P = 0.013). Perioperative SARS-CoV-2 infection was not associated with "major cardiorespiratory complications" or "liver resection-specific complications", but age, pre-existing comorbidities, and tumor type were related to these outcomes.

CONCLUSION

Perioperative SARS-CoV-2 Omicron infection did not increase the incidence of postoperative complications in patients with liver cancer. However, those patients had a higher rate of 30-day readmission after surgery.

Incisional Hernia After Laparoscopic Right Colectomy for Colorectal Cancer: A Prospective Study with Retrospective Control on Intracorporeal Versus Extracorporeal Anastomosis

Background: Incisional hernias often occur after laparoscopic colorectal surgery, but the precise risk factors are not fully understood. This study's primary aim was to compare the incidence of incisional hernias following laparoscopic right colectomy with intracorporeal anastomotic reconstruction (ICA) versus extracorporeal anastomotic reconstruction (ECA). Materials and Methods: A cohort study compared two groups of patients who underwent elective laparoscopic right colectomy for colon cancer following a standardized perioperative enhanced recovery program (ERP): a prospective group underwent ICA from January 2018 to February 2020 and a retrospective group underwent ECA from January 2013 to December 2016. The presence of incisional hernias was assessed by reviewing patients' follow-up computed tomography scans or evaluating the patients by telephone interview or outpatient office visit and diagnostic imaging. Secondary objectives included the hospital length of stay, postoperative complications, 30-day readmission rate, reoperation, and mortality. Results: The study included 89 patients who had laparoscopic right colectomy for malignant colon neoplasms. Among these, 48 underwent ECA (ECA group), and 41 had ICA (ICA group). At a median follow-up of 36 months, incisional hernia was observed in 1 patient (2.4%) in the ICA group, in contrast to 11 (22.9%) confirmed cases in the ECA group (P = .010). The length of hospital stay was similar between the two groups (5 days versus 4 days; P = .064). The two groups showed similarities in terms of postoperative complications (P = .093), hospital readmission (P = .999), and the rate of reoperation within 30 days (P = .461). Conclusions: The ICA technique was associated with a reduced risk of incisional hernias compared with the ECA technique, with similar outcomes in short-term postoperative complications and overall patient recovery.

C-reactive protein to albumin ratio may predict in-hospital mortality in non-ST elevation myocardial infarction

Objective: The authors investigated the value of novel inflammatory markers, systemic immune-inflammation index and C-reactive protein to albumin ratio (CAR), to predict in-hospital mortality in patients with non-ST elevation myocardial infarction (NSTEMI). Materials & methods: A total of 308 patients who underwent percutaneous coronary intervention because of NSTEMI were retrospectively included in the study. Killip classification, Thrombolysis in Myocardial Infarction score, SYNTAX score, and CAR and systemic immune-inflammation index values were calculated. Results: CAR (cutoff: 0.0864; sensitivity: 94.1%; specificity: 40.5%; p = 0.008) and Killip classification (cutoff: 2.5; sensitivity: 64.7%; specificity: 8.9%; p = 0.001) were found to be significantly higher in determining in-hospital mortality. Conclusion: This study revealed that CAR is an inexpensive and significant factor in predicting in-hospital mortality in patients undergoing percutaneous coronary intervention for NSTEMI.

Diagnosis and management of endometrial hyperplasia: A UK national audit of adherence to national guidance 2012-2020

BACKGROUND

Endometrial hyperplasia (EH) is a precusor lesion for endometrial cancer (EC), the commonest gynaecological malignancy in high-income countries. EH is a proliferation of glandular tissue, classified as either non-atypical endometrial hyperplasia (NEH) or, if the cytological features are abnormal, atypical endometrial hyperplasia (AEH). The clinical significance of AEH is that patients face both a high risk of having occult EC and a high risk of progression to EC if untreated. Recommendations on the care of women with EH were introduced by United Kingdom-wide guidance (Green-top Guide No. 67, 2016). National adherence to guidance is unknown. We aimed to describe the care of patients with EH; to compare the patterns of care for those with EH with national guidance to identify opportunities for quality improvement; and to compare patterns of care prior to and following the introduction of national guidance to understand its impact.

METHODS AND FINDINGS

In this UK-wide patient-level clinical audit, we included 3,307 women who received a new histological diagnosis of EH through a gynaecology service between 1 January 2012 and 30 June 2020. We described first-line management, management at 2 years, and surgical characteristics prior to and following national guidance for EH using proportions and 95% confidence intervals (CIs) and compared process measures between time periods using multilevel Poisson regression. Of the 3,307 patients, 1,570 had NEH and 1,511 had AEH between 2012 and 2019. An additional 85 patients had NEH and 141 had AEH during 2020. Prior to national guidance, 9% (95% CI [6%, 15%]) received no initial treatment for NEH compared with 3% (95% CI [1%, 5%]) post-guidance; 31% (95% CI [26%, 36%]) and 48% (95% CI [43% 53%]) received an intrauterine progestogen, respectively, in the same periods. The predominant management of women with AEH did not differ, with 68% (95% CI [61%, 74%]) and 67% (95 CI [63%, 71%]) receiving first-line hysterectomy, respectively. By 2 years, follow-up to histological regression without hysterectomy increased from 38% (95% CI [33%, 43%]) to 52% (95% CI [47%, 58%]) for those with NEH (rate ratio (RR) 1.38, 95% CI [1.18, 1.63] p < 0.001). We observed an increase in the use of total laparoscopic hysterectomy among those with AEH (RR 1.26, 95% CI [1.04, 1.52]). In the later period, 37% (95% CI [29%, 44%]) of women initially diagnosed with AEH who underwent a first-line hysterectomy, received an upgraded diagnosis of EC. Study limitations included retrospective data collection from routine clinical documentation and the inability to comprehensively understand the shared decision-making process where care differed from guidance.

CONCLUSIONS

The care of patients with EH has changed in accordance with national guidance. More women received first-line medical management of NEH and were followed up to histological regression. The follow-up of those with AEH who do not undergo hysterectomy must be improved, given their very high risk of coexistent cancer and high risk of developing cancer.

The diagnostic role of the systemic inflammation index in patients with immunological diseases: a systematic review and meta-analysis

The identification of novel, easily measurable biomarkers of inflammation might enhance the diagnosis and management of immunological diseases (IDs). We conducted a systematic review and meta-analysis to investigate an emerging biomarker derived from the full blood count, the systemic inflammation index (SII), in patients with IDs and healthy controls. We searched Scopus, PubMed, and Web of Science from inception to 12 December 2023 for relevant articles and evaluated the risk of bias and the certainty of evidence using the Joanna Briggs Checklist and the Grades of Recommendation, Assessment, Development, and Evaluation Working Group system, respectively. In 16 eligible studies, patients with IDs had a significantly higher SII when compared to controls (standard mean difference, SMD = 1.08, 95% CI 0.75 to 1.41, p < 0.001; I2 = 96.2%, p < 0.001; moderate certainty of evidence). The pooled area under the curve (AUC) for diagnostic accuracy was 0.85 (95% CI 0.82-0.88). In subgroup analysis, the effect size was significant across different types of ID, barring systemic lupus erythematosus (p = 0.20). In further analyses, the SII was significantly higher in ID patients with active disease vs. those in remission (SMD = 0.81, 95% CI 0.34-1.27, p < 0.001; I2 = 93.6%, p < 0.001; moderate certainty of evidence). The pooled AUC was 0.74 (95% CI 0.70-0.78). Our study suggests that the SII can effectively discriminate between subjects with and without IDs and between ID patients with and without active disease. Prospective studies are warranted to determine whether the SII can enhance the diagnosis of IDs in routine practice. (PROSPERO registration number: CRD42023493142).

Effects on Cancer Prevention from the COVID-19 Pandemic

The COVID-19 pandemic led to disruption of health services around the world, including cancer services. We carried out a narrative review of the effect of the pandemic on cancer prevention services, including screening. Services were severely affected in the early months of the pandemic, and in some areas are still recovering. Large numbers of additional cancers or additional late-stage cancers have been predicted to arise over the coming years as a result of this disruption. To minimize the effects on cancer outcomes, it is necessary to return as quickly as possible to prepandemic levels of screening and prevention activity or indeed to exceed these levels. The recovery of services should address health inequalities.

Cost-Effectiveness of Universal Asymptomatic Preoperative SARS-CoV-2 Polymerase Chain Reaction Screening: A Cost-Utility Analysis

BACKGROUND

An early report has shown the clinical benefit of the asymptomatic preoperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) screening test, and some clinical guidelines recommended this test. However, the cost-effectiveness of asymptomatic screening was not evaluated. We aimed to investigate the cost-effectiveness of universal preoperative screening of asymptomatic patients for SARS-CoV-2 using polymerase chain reaction (PCR) testing.

METHODS

We evaluated the cost-effectiveness of asymptomatic screening using a decision tree model from a payer perspective, assuming that the test-positive rate was 0.07% and the screening cost was 8500 Japanese yen (JPY) (approximately 7601 US dollars [USD]). The input parameter was derived from the available evidence reported in the literature. A willingness-to-pay threshold was set at 5 000 000 JPY/quality-adjusted life-year (QALY).

RESULTS

The incremental cost of 1 death averted was 74 469 236 JPY (approximately 566 048 USD) and 291 123 368 JPY/QALY (approximately 2 212 856 USD/QALY), which was above the 5 000 000 JPY/QALY willingness-to-pay threshold. The incremental cost-effectiveness ratio fell below 5 000 000 JPY/QALY only when the test-positive rate exceeded 0.739%. However, when the probability of developing a postoperative pulmonary complication among SARS-CoV-2-positive patients was below 0.22, asymptomatic screening was never cost-effective, regardless of how high the test-positive rate became.

CONCLUSIONS

Asymptomatic preoperative universal SARS-CoV-2 PCR screening is not cost-effective in the base case analysis. The cost-effectiveness mainly depends on the test-positive rate, the frequency of postoperative pulmonary complications, and the screening costs; however, no matter how high the test-positive rate, the cost-effectiveness is poor if the probability of developing postoperative pulmonary complications among patients positive for SARS-CoV-2 is sufficiently reduced.

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

BACKGROUND

SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice.

METHODS

This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure.

RESULTS

Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management.

CONCLUSIONS

There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training.

TRIAL REGISTRATION

The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020.

Cystic Echinococcosis in Hospitalized Children from Western Romania: A 25-Year Retrospective Study

Cystic echinococcosis (CE) is a cosmopolitan parasitic disease caused by Echinococcus granulosus. We aimed to assess the epidemiological aspects of the disease in hospitalized children from Western Romania, a well-known endemic area for CE. We retrospectively investigated the medical records of children hospitalized between 1998 and 2022. A total of 144 patients were included, and 58.3% were from rural areas. The number of cases increased with age, from 9% in the age group 3-5 years to 59.7% in the age group 11-17 years. The liver was more frequently affected (65.3%), and a significant association between gender and the affected organ was noted; liver cysts were more frequently diagnosed in girls, while lung cysts were recorded mostly in boys. Complications were more frequently reported in patients with pulmonary CE compared to hepatic CE (p = 0.04). Boys had more complications (16/23, 69.6%) compared to girls (7/23, 30.4%) (p = 0.03). A third of the children were hospitalized for more than 14 days, and multiple hospitalizations were recorded in 31.3% of the patients. This paper provides new insights into the epidemiologic features of cystic echinococcosis in children from Western Romania. Our findings indicate that exposure to the parasite starts in childhood, and the rate of hospitalization increases with age. Public health strategies should be implemented and permanently improved in order to lower the prevalence of CE in children.

Effect of adjuvant chemotherapy on the oncological outcome of rectal cancer patients with pathological complete response

BACKGROUND

Locally advanced rectal cancer is typically treated using a combination of neoadjuvant chemoradiotherapy and total mesorectal resection. While achieving pathological complete response following neoadjuvant chemoradiotherapy has been recognized as a positive prognostic factor in oncology, the necessity of adjuvant chemotherapy for locally advanced rectal cancer patients with pathological complete response after surgery remains uncertain. The objective of this meta-analysis was to examine the impact of adjuvant chemotherapy on the oncological outcomes of rectal cancer patients who attain pathological complete response after neoadjuvant chemoradiotherapy.

METHODS

This meta-analysis followed the guidelines outlined in the preferred reporting items for systematic review and meta-analysis (PRISMA). The Web of Science, PubMed, and Cochrane Library databases were systematically searched to identify relevant literature.

RESULTS

A total of 34 retrospective studies, including 9 studies from the NCBD database, involving 31,558 patients with pathological complete response rectal cancer, were included in the meta-analysis. The included studies were published between 2008 and 2023. The pooled analysis demonstrated that adjuvant chemotherapy significantly improved overall survival (HR = 0.803, 95% CI 0.678-0.952, P = 0.011), and no heterogeneity was observed (I2 = 0%). Locally advanced rectal cancer patients with pathological complete response who underwent adjuvant chemotherapy exhibited a higher 5-year overall survival rate compared to those who did not receive adjuvant chemotherapy (OR = 1.605, 95% CI 1.183-2.177, P = 0.002). However, the analysis also revealed that postoperative ACT did not lead to improvements in disease-free survival and recurrence-free survival within the same patient population. Subgroup analysis indicated that pathological complete response patients with clinical stage T3/T4, lymph node positivity, and younger than 70 years of age may benefit from adjuvant chemotherapy in terms of overall survival.

CONCLUSIONS

The findings of this meta-analysis suggest that adjuvant chemotherapy has a beneficial effect on improving overall survival among rectal cancer patients with pathological complete response. However, no such association was observed in terms of disease-free survival and recurrence-free survival.

Poor nutritional status is associated with the severity of omicron infection in the older adults

BACKGROUND

The Omicron wave of Coronavirus disease 2019 (COVID-19) remains the dominant strain worldwide. The studies of nutritional status in geriatric people with COVID-19 Omicron variant are limited. Thus, the aim of this study was to investigate the incidence of poor nutritional status among Omicron infected older patients, and to explore the correlation between the nutritional status and the severity of Omicron infection in older patients.

METHODS

This is a retrospective cross-sectional study. According to the clinical symptoms, patients were divided into two groups: mild and moderate to severe. Mini Nutritional Assessment short-form (MNA-SF) was conducted when patients were admitted and poor nutritional status was defined as MNA-SF score of 0-11. The inflammatory markers including neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and systemic inflammatory index (SII) were calculated and compared between two groups.

RESULTS

Total of 324 patients were enrolled, with median [interquartile range (IQR)] age of 73 (17) years. Overall, 241 cases were mild, 83 cases were moderate to severe at the time of diagnosis and that 54.3% of patients had poor nutritional status. Patients with poor nutritional status were found to be older (P < 0.001) and less vaccinated (P < 0.001), with a longer virus shedding duration (P = 0.022), more comorbidities (≥ 2) (P = 0.004) and higher value of NLR (P < 0.001), PLR (P < 0.001) and SII (P = 0.012). Vaccination, cycle threshold value in ORF1ab gene (OR CT value) and female, higher MNA-SF score was negatively connected with probability of moderate to severe infection. For every 1 score increase in MNA-SF, the odds ratio of moderate to severe infection decreased by 14.8% [adjusted odds ratio (aOR), 0.852; 95% confidence interval (CI): 0.734-0.988; P = 0.034].

CONCLUSIONS

Older patients with poor nutritional status are more likely to develop moderate to severe Omicron infection.

Meta-analysis of the systemic immune-inflammatory index and in-hospital mortality of COVID-19 patients

Background

The potential significance of immunoinflammatory factors in the prognosis of individuals afflicted with coronavirus disease 2019 (COVID-19) is worthy of examination. The systemic immune-inflammatory index (SII), a recently developed immunoinflammatory metric based on the enumeration of neutrophils, platelets, and lymphocytes in blood samples, holds promise for elucidating this relationship. Consequently, in order to explore any possible correlation between the SII levels at admission and the in-hospital mortality of patients with COVID-19, we undertook a thorough systematic review and meta-analysis.

Methods

In pursuit of accomplishing the aim of this meta-analysis, an extensive search was conducted to seek out pertinent observational studies featuring longitudinal follow-up across PubMed, Cochrane Library, Embase and the Web of Science databases. The I2 statistic was utilized to estimate the extent of heterogeneity and the Cochrane Q test was employed to evaluate heterogeneity between studies. The synthesis of outcomes involved the use of random-effects models, accounting for the possible influence of heterogeneity.

Results

Our analysis included sixteen studies, encompassing 10,007 hospitalized COVID-19 patients. Among them, 1801 patients (18.0 %) succumbed during hospitalization. The pooled results indicated that a high SII at admission was substantially linked to a higher risk of all-cause mortality (risk ratio [RR]: 2.41, 95 % confidence interval: 1.78 to 3.24, p < 0.001; I2 = 86 %). Meta-regression analysis demonstrated a negative correlation between mean SII at baseline and patient mortality in individual studies (coefficients = -0.00023 and -0.030, p < 0.05), effectively explaining the observed heterogeneity. Furthermore, in patients with lower baseline SII (<1300) and a lower risk of mortality (<20 %), we observed a more pronounced association between high SII levels and the risk of all-cause mortality.

Conclusion

The results of our study indicate that a high SII upon admission could potentially function as a prognostic indicator for mortality during hospitalization in patients diagnosed with COVID-19, particularly in individuals categorized as low risk.

Advancements and hurdles in the development of a vaccine for triple-negative breast cancer: A comprehensive review of multi-omics and immunomics strategies

Triple-Negative Breast Cancer (TNBC) presents a significant challenge in oncology due to its aggressive behavior and limited therapeutic options. This review explores the potential of immunotherapy, particularly vaccine-based approaches, in addressing TNBC. It delves into the role of immunoinformatics in creating effective vaccines against TNBC. The review first underscores the distinct attributes of TNBC and the importance of tumor antigens in vaccine development. It then elaborates on antigen detection techniques such as exome sequencing, HLA typing, and RNA sequencing, which are instrumental in identifying TNBC-specific antigens and selecting vaccine candidates. The discussion then shifts to the in-silico vaccine development process, encompassing antigen selection, epitope prediction, and rational vaccine design. This process merges computational simulations with immunological insights. The role of Artificial Intelligence (AI) in expediting the prediction of antigens and epitopes is also emphasized. The review concludes by encapsulating how Immunoinformatics can augment the design of TNBC vaccines, integrating tumor antigens, advanced detection methods, in-silico strategies, and AI-driven insights to advance TNBC immunotherapy. This could potentially pave the way for more targeted and efficacious treatments.

Performance and Dimensionality of Pretreatment MRI Radiomics in Rectal Carcinoma Chemoradiotherapy Prediction

(1) Background: This study aimed to develop a machine learning model based on radiomics of pretreatment magnetic resonance imaging (MRI) 3D T2W contrast sequence scans combined with clinical parameters (CP) to predict neoadjuvant chemoradiotherapy (nCRT) response in patients with locally advanced rectal carcinoma (LARC). The study also assessed the impact of radiomics dimensionality on predictive performance. (2) Methods: Seventy-five patients were prospectively enrolled with clinicopathologically confirmed LARC and nCRT before surgery. Tumor properties were assessed by calculating 2141 radiomics features. Least absolute shrinkage selection operator (LASSO) and multivariate regression were used for feature selection. (3) Results: Two predictive models were constructed, one starting from 72 CP and 107 radiomics features, and the other from 72 CP and 1862 radiomics features. The models revealed moderately advantageous impact of increased dimensionality, with their predictive respective AUCs of 0.86 and 0.90 in the entire cohort and 0.84 within validation folds. Both models outperformed the CP-only model (AUC = 0.80) which served as the benchmark for predictive performance without radiomics. (4) Conclusions: Predictive models developed in this study combining pretreatment MRI radiomics and clinicopathological features may potentially provide a routine clinical predictor of chemoradiotherapy responders, enabling clinicians to personalize treatment strategies for rectal carcinoma.

Impact of COVID-19 Pandemic Surge on Surgical Outcomes: A Retrospective Study

BACKGROUND

The COVID-19 pandemic posed significant challenges to healthcare systems worldwide, including surgical care. While many studies examined the effect of the pandemic on different patient outcomes, there are none to date examining the impact of the pandemic surge on surgical outcomes. Our aim is to evaluate the impact of the COVID-19 surges on surgical outcomes using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

A single-center retrospective analysis of 7436 patients who underwent surgery between February 2020 and December 2022 was conducted. Patients were divided into those who underwent surgery during the surge of the pandemic (n = 1217) or outside that period (n = 6219). Primary outcomes were 30-day mortality and morbidity. Secondary outcomes included 30-day mortality, operation time, transfusion, reoperation, and specific postoperative complications. Multivariable logistic regression was used in our analysis. All analyses were conducted using the software "R" version 4.2.1. Statistical significance was set at α = .05 level.

RESULTS

After adjusting for confounders, we found no significant difference in 30-day mortality and morbidity (OR: 1.06, 95% CI: .89-1.226, P = .5173) or 30-day mortality only (OR: 1.39, 95% CI: .788-2.14, P = .1364) between the two groups. No significant differences were observed in secondary outcomes. Sensitivity analyses yielded similar results to the multivariable logistic regression.

CONCLUSION

We found no evidence of increased 30-day mortality and morbidity in patients undergoing surgery during the COVID-19 surges compared to those undergoing surgery outside that period. Our results suggest that surgical care was maintained despite the challenges of the pandemic surges.

Trends in inequalities in avoidable hospitalisations across the COVID-19 pandemic: a cohort study of 23.5 million people in England

OBJECTIVE

To determine whether periods of disruption were associated with increased 'avoidable' hospital admissions and wider social inequalities in England.

DESIGN

Observational repeated cross-sectional study.

SETTING

England (January 2019 to March 2022).

PARTICIPANTS

With the approval of NHS England we used individual-level electronic health records from OpenSAFELY, which covered ~40% of general practices in England (mean monthly population size 23.5 million people).

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated crude and directly age-standardised rates for potentially preventable unplanned hospital admissions: ambulatory care sensitive conditions and urgent emergency sensitive conditions. We considered how trends in these outcomes varied by three measures of social and spatial inequality: neighbourhood socioeconomic deprivation, ethnicity and geographical region.

RESULTS

There were large declines in avoidable hospitalisations during the first national lockdown (March to May 2020). Trends increased post-lockdown but never reached 2019 levels. The exception to these trends was for vaccine-preventable ambulatory care sensitive admissions which remained low throughout 2020-2021. While trends were consistent by each measure of inequality, absolute levels of inequalities narrowed across levels of neighbourhood socioeconomic deprivation, Asian ethnicity (compared with white ethnicity) and geographical region (especially in northern regions).

CONCLUSIONS

We found no evidence that periods of healthcare disruption from the COVID-19 pandemic resulted in more avoidable hospitalisations. Falling avoidable hospital admissions has coincided with declining inequalities most strongly by level of deprivation, but also for Asian ethnic groups and northern regions of England.

Long-term risk prediction after major lower limb amputation: 1-year results of the PERCEIVE study

BACKGROUND

Decision-making when considering major lower limb amputation is complex and requires individualized outcome estimation. It is unknown how accurate healthcare professionals or relevant outcome prediction tools are at predicting outcomes at 1-year after major lower limb amputation.

METHODS

An international, multicentre prospective observational study evaluating healthcare professional accuracy in predicting outcomes 1 year after major lower limb amputation and evaluation of relevant outcome prediction tools identified in a systematic search of the literature was undertaken. Observed outcomes at 1 year were compared with: healthcare professionals' preoperative predictions of death (surgeons and anaesthetists), major lower limb amputation revision (surgeons) and ambulation (surgeons, specialist physiotherapists and vascular nurse practitioners); and probabilities calculated from relevant outcome prediction tools.

RESULTS

A total of 537 patients and 2244 healthcare professional predictions of outcomes were included. Surgeons and anaesthetists had acceptable discrimination (C-statistic = 0.715), calibration and overall performance (Brier score = 0.200) when predicting 1-year death, but performed worse when predicting major lower limb amputation revision and ambulation (C-statistics = 0.627 and 0.662 respectively). Healthcare professionals overestimated the death and major lower limb amputation revision risks. Consultants outperformed trainees, especially when predicting ambulation. Allied healthcare professionals marginally outperformed surgeons in predicting ambulation. Two outcome prediction tools (C-statistics = 0.755 and 0.717, Brier scores = 0.158 and 0.178) outperformed healthcare professionals' discrimination, calibration and overall performance in predicting death. Two outcome prediction tools for ambulation (C-statistics = 0.688 and 0.667) marginally outperformed healthcare professionals.

CONCLUSION

There is uncertainty in predicting 1-year outcomes following major lower limb amputation. Different professional groups performed comparably in this study. Two outcome prediction tools for death and two for ambulation outperformed healthcare professionals and may support shared decision-making.

The residual cancer burden index as a valid prognostic indicator in breast cancer after neoadjuvant chemotherapy

PURPOSE

The residual cancer burden index (RCB) was proposed as a response evaluation criterion in breast cancer patients treated with Neoadjuvant Chemotherapy (NAC). This study evaluated the relevance of RCB with replase-free survival (RFS).

METHODS

The clinical data of 254 breast cancer patients who received NAC between 2016 and 2020 were retrospectively collected. The relationship between clinicopathologic factors and RFS was evaluated using Cox proportional hazards regression models. RFS estimates were determined by Kaplan-Meier(K-M) analysis and compared using the log-rank test. Multivariate logistic regression analysis was used to evaluate the risk factors associated with RCB. Receiver operating characteristic (ROC) curves showed the potential of the RCB and MP grading systems as biomarkers for RFS.

RESULTS

At a median follow-up of 52 months, 59 patients(23.23%) developed relapse. Multivariate Cox regression showed that older age (P = 0.022), high Pathologic T stage after NAC (P = 0.023) and a high RCB score(P = 0.003) were risk factors for relapse. The outcomes of the multivariate logistic analysis indicated that RCB 0 (pathologic complete response [pCR]) was associated with HER2-positive patients (P = 0.002) and triple-negative breast cancer (TNBC) patients (P = 0.013). In addition, the RCB and MP scoring systems served as prognostic markers for patients who received NAC, and their area under curves (AUCs) were 0.691 and 0.342, respectively.

CONCLUSION

These data suggest that RCB can be equally applied to predict RFS in Chinese patients with NAC. The application of RCB may help guide the selection of treatment strategies.

Optimum timing of lung resection surgery following SARS-CoV-2 infection for non-small cell lung cancer

BACKGROUND

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on postoperative recovery of non-small cell lung cancer (NSCLC) is need to be understood, thereby informing the optimal timing of surgical decision-making during the COVID-19 pandemic for NSCLC patients. This study reports the postoperative outcomes of surgical NSCLC patients with preoperative SARS-CoV-2 infection.

METHOD

This single-center retrospective cohort study included 241 NSCLC patients who underwent lobectomy or sub-lobectomy between December 1, 2022 and February 14, 2023. Surgical outcomes of patients with preoperative SARS-CoV-2 infection (stratified by the time from diagnosis of SARS-CoV-2 infection to surgery) were compared with those without preoperative SARS-CoV-2 infection. The primary outcomes were total postoperative complications and postoperative pulmonary complications (PPCs), the secondary outcomes included operation time, total postoperative drainage and time, length of hospital stay (LOS), 30-day and 90-day postoperative symptoms.

RESULTS

This study included 153 (63.5%) patients with preoperative SARS-CoV-2 infection and 88 (36.5%) patients without previous SARS-CoV-2 infection. In patients with a preoperative SARS-CoV-2 diagnosis, the incidence of total postoperative complications (OR, 3.00; 95% CI, 1.12-8.01; p = 0.028) and PPCs (OR, 4.20; 95% CI, 1.11-15.91; p = 0.035) both increased in patients infected having surgery within 2 weeks compared with non-infection before surgery. However, patients who underwent lung resection more than 2 weeks after SARS-CoV-2 diagnosis had a similar risk of postoperative complications and surgical outcomes with those non-infection before surgery.

CONCLUSION

This is the first study to provide evidence regarding the optimum timing of lung resection surgery and assessing early outcomes after surgery in NSCLC patients with SARS-CoV-2 infection. Our study documents that the SARS-CoV-2 infection did not complicate surgical procedures for lung cancer, and suggest that lung surgery should be postponed at least 2 weeks after SARS-CoV-2 infection for NSCLC patients.

International Hepato-Pancreato-Billiary Association (IHPBA) registry study on COVID-19 infections in HPB surgery patients

BACKGROUND

In response to the pandemic, the International Hepato-Pancreato-Biliary Association (IHPBA) developed the IHPBA-COVID Registry to capture data on HPB surgery outcomes in COVID-positive patients prior to mass vaccination programs. The aim was to provide a tool to help members gain a better understanding of the impact of COVID-19 on patient outcomes following HPB surgery worldwide.

METHODS

An online registry updated in real time was disseminated to all IHPBA, E-AHPBA, A-HPBA and A-PHPBA members to assess the effects of the pandemic on the outcomes of HPB procedures, perioperative COVID-19 management and other aspects of surgical care.

RESULTS

One hundred twenty-five patients from 35 centres in 18 countries were included. Seventy-three (58%) patients were diagnosed with COVID-19 preoperatively. Operative mortality after pancreaticoduodenectomy and major hepatectomy was 28% and 15%, respectively, and 2.5% after cholecystectomy. Postoperative complication rates of pancreatic procedures, hepatic interventions and biliary interventions were respectively 80%, 50% and 37%. Respiratory complication rates were 37%, 31% and 10%, respectively.

CONCLUSION

This study reveals a high risk of mortality and complication after HPB surgeries in patient infected with COVID-19. The more extensive the procedure, the higher the risk. Nonetheless, an increased risk was observed across all types of interventions, suggesting that elective HPB surgery should be avoided in COVID positive patients, delaying it at distance from the viral infection.

Considerations for Perioperative Thromboembolic Risk Mitigation in Actively and Recently COVID-19-Positive Patients Undergoing Hand Surgery

Coronavirus Disease 2019 (COVID) induces a hypercoagulable state causing an increased risk of venous and arterial thromboses. Distal limb and microvascular circulation are critical to the success of many hand surgeries, and patients who are actively or recently infected with COVID may be at a higher risk for perioperative thrombotic events. Little information is available regarding how to handle actively or recently infected COVID patients, including preoperative risk assessment, intraoperative decision making, and postoperative considerations regarding thrombotic risk. Our aim was to review the literature to determine how the hand surgeon can best prepare for and manage the actively or recently COVID-positive patients undergoing hand surgeries.

Hepatic Benign Cystic Mesothelioma in Adults: A Case Report of a Rare Hepatic Cyst

Benign cystic mesothelioma (BCM), also known as peritoneal inclusion cyst, is a benign mesothelial lined cystic lesion, nearly always described in the pelvis of adult females. The hepatic location of BCM is rarely reported in the literature. We report a case of hepatic benign cysts in a 65-year-old woman that was incidentally discovered by imaging studies 12 years ago as a small cyst. Recently, the patient started having abdominal discomfort, distension, and anxiety. A CT scan revealed two low-density fluid-filled cystic lesions, the largest in the caudate lobe measuring up to 10.7 cm and causing a mass effect on hepatic veins and inferior vena cava. Laparoscopic marsupialization of the large liver cyst was done without complications. On gross examination, the collapsed cyst wall was a thin partly translucent pale tan to pink membranous structure with fine vascularity. No discrete nodularity or solid lesion was identified. Microscopic examination showed a thin fibro-connective wall lined by a single layer of flat cuboidal cells with no cellular atypia. The cyst lining showed characteristic calretinin-positive immunohistochemical reactivity for mesothelium, supporting the diagnosis of BCM. Hepatic BCM is among a broad differential spectrum of cystic liver lesions ranging from developmental, reactive, inflammatory, and infectious lesions, benign to premalignant or frankly malignant neoplasms with different treatment strategies. Although BCM is the rarest among the long list of differential diagnoses of hepatic cysts, its identification in this rarely reported location is essential to avoid aggressive surgical treatment.

Survival analysis in association with GST gene polymorphism and Treatment outcomes of Gemcitabine and Cisplatin/Carboplatin-based chemotherapy among patients with Gallbladder Carcinoma

PURPOSE

Majority of the gallbladder cancer (GBC) cases are diagnosed at an advanced stage where chemotherapy alone (or in combination with other treatment methods) is mainly opted as therapeutic approach. However, success or failure of this approach largely depends on the interindividual genetic differences. Careful consideration on the genetic association could assist in the evaluation of patient's treatment response and survival rate. Hence, the present study aims to investigate the survival of patients with GBC and their treatment response to gemcitabine and cisplatin/carboplatin-based chemotherapy in association with Glutathione S-transferase (GSTs) gene polymorphism.

MATERIAL AND METHODS

A total of 216 histologically confirmed cases of gallbladder cancer were recruited. A total of 180 patients were treated with gemcitabine and cisplatin/carboplatin-based chemotherapy. GSTM1, GSTT1, and GSTP1 genotypes were determined by multiplex PCR and by PCR restriction fragment length polymorphism (PCR-RFLP), respectively. The influence of genetic polymorphism on overall survival was analyzed by Kaplan-Meier method, survival rate difference was analyzed by log-rank test, and hazard ratio for mortality outcomes was estimated using Cox regression method.

RESULTS

GBC patients having genotype GSTP1 (AG + GG) showed poor 3-year survival rate of 0.8% compared to 10.9% of GSTP1 (AA) genotype (χ2 = 6.456, P = 0.011). The multivariate Cox regression results showed that the death risk was significantly higher in GSTP1 (AG + GG) genotype (HR = 3.858, P = 0.050). We found no association of GSTM1 and GSTT1 gene polymorphism with the survival; however, the combined genotypes of GSM1/GSTP1, GSTT1/GSTP1, and GSTM1/GSTT1/GSTP1 were associated with survival (P = 0.053, 0.006, and 0.058, respectively). Increased death hazard was noted by the genotype combinations of GSTM1+/GSTP1AG + GG (HR = 3.484, P = 0.024), GSTM1-/GSTP1AG + GG (HR = 2.721, P = 0.014), GSTT1+/GSTP1AG + GG (HR = 20.690, P = 0.001), and GSTT1-/GSTP1AA (HR = 26.111, P < 0.0001). Our findings indicate that chemotherapy treatment response of GSTP1 (AG + GG) has 1.62-fold increased risk for progression compared to GSTP1 (AA) genotype (p = 0.018); however, none of the genotypes showed association with overall survival and death risk after chemotherapeutic treatment.

CONCLUSION

We found that the presence of GSTP1 (AG + GG) genotype showed survival disadvantage and poor treatment outcomes in response to gemcitabine and cisplatin/carboplatin-based chemotherapy. This could serve as biomarker, and future research in pharmacogenomics will definitely pave the way for the development of better treatment approach for GBC.

Minimally invasive versus open radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma: an entropy balancing analysis

BACKGROUND

The safety and efficacy of minimally invasive radical antegrade modular pancreatosplenectomy (MI-RAMPS) remain to be established in pancreatic cancer (PDAC) METHODS: Eighty-five open (O)-RAMPS were compared to 93 MI-RAMPS. The entropy balance matching approach was used to compare the two cohorts, eliminating the selection bias. Three models were created. Model 1 made O-RAMPS equal to the MI-RAMPS cohort (i.e., compared the two procedures for resectable PDAC); model 2 made MI-RAMPS equal to O-RAMPS (i.e., compared the two procedures for borderline-resectable PDAC); model 3, compared robotic and laparoscopic RAMPS.

RESULTS

O-RAMPS and MI-RAMPS showed "non-small" differences for BMI, comorbidity, back pain, tumor size, vascular resection, anterior or posterior RAMPS, multi-visceral resection, stump management, grading, and neoadjuvant therapy. Before reweighting, O-RAMPS had fewer clinically relevant postoperative pancreatic fistulae (CR-POPF) (20.0% vs. 40.9%; p = 0.003), while MI-RAMPS had a higher mean of lymph nodes (25.7 vs. 31.7; p = 0.011). In model 1, MI-RAMPS and O-RAMPS achieved similar results. In model 2, O-RAMPS was associated with lower comprehensive complication index scores (MD = 11.2; p = 0.038), and CR-POPF rates (OR = 0.2; p = 0.001). In model 3, robotic-RAMPS had a higher probability of negative resection margins.

CONCLUSION

In patients with anatomically resectable PDAC, MI-RAMPS is feasible and as safe as O-RAMPS.

National Cross-Sectional Epidemiological Analysis of the Impact of Pandemic COVID-19 on Vascular Procedures in Public Health System: 521,069 Procedures Over 4 Years

BACKGROUND

During the COVID-19 pandemic, there was a dramatic increase in healthcare demand. Resources were redirected to care patients with COVID-19. Therefore, surgical treatments were affected, including those of vascular diseases. There are no studies evaluating the whole impact of the COVID-19 pandemic, considering all types of vascular procedures, both elective and urgent, in a large country. The aim of the present study was to analyze the impact on all types of vascular procedures performed in Brazilian public hospitals during the COVID-19 pandemic.

METHODS

Cross-sectional population-based analysis of publicly available data referring to vascular procedures. Surgeries 2 years before the pandemic onset (2018-2019) and 2 years during pandemic (2020-2021) were included.

RESULTS

We observed a total of 521,069 procedures. Decrease was observed in elective abdominal aortic aneurysm repairs both open surgery (P = 0.001) and endovascular surgery (P < 0.001), emergency open abdominal repairs (P = 0.005), elective thoracic aortic aneurysm repairs (P = 0.007), elective open peripheral aneurysm repairs (P = 0.038), carotid endarterectomies (P < 0.001) and angioplasties (P = 0.001), open revascularizations for peripheral arterial disease (P < 0.001), surgical treatment of chronic venous disease (P < 0.001) and sympathectomies for hyperhidrosis (P < 0.001). However, there was an increase of lower limb amputations (P = 0.027) and vena cava filter placements (P = 0.005). There was a reduction of almost US$17 million in financial investments.

CONCLUSIONS

The reorganization of health systems led to a significant reduction in vascular procedures and decrease in financial investments. On the other hand, there was a significant increase in the number of lower limb amputations and vena cava filter placements.

Safety and local efficacy of computed tomography-guided microwave ablation for treating early-stage non-small cell lung cancer adjacent to bronchovascular bundles

OBJECTIVES

To retrospectively evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous microwave ablation in treating early-stage non-small cell lung cancer (NSCLC) adjacent to bronchovascular bundles.

METHODS

Two hundred and thirty-one patients with early-stage NSCLC who underwent CT-guided microwave ablation of the tumor were included for analysis. Among these, 66 lesions were located adjacent to the bronchovascular bundle. Achievement of the specific ablation range (defined as the ablation zone encompassing the tumor and the adjacent vessel) was assessed after ablation. Complications and tumor progression after treatment were examined and compared between the bronchovascular bundle and non-bronchovascular bundle groups.

RESULTS

A total of 231 patients were included. Overall, 1-, 2-, and 3-year local progression-free survival (LPFS) was 77.4%, 70.5%, and 63.8%, respectively. Bronchovascular bundle proximity, pure-solid tumor, tumor size, and ablation margin < 5 mm were independent risk factors for local progression in multivariate analysis. In the bronchovascular bundle group, the 1-, 2- and 3-year LPFS rates were 63.0%, 50.7%, and 43.4%, respectively; vessel proximity and specific ablation range failure were independent risk factors for local progression. Overall survival in the entire cohort was 93.0% at 1 year, 76.1% at 2 years, and 55.0% at 3 years. The incidence of postoperative complications did not significantly differ between the two groups (p > 0.05). The most common complication was pneumothorax. Severe hemoptysis did not occur.

CONCLUSION

Tumor location near the bronchovascular bundles was a significant risk factor for local progression after microwave ablation. Achieving a specific ablation range may increase LPFS for these lesions.

CLINICAL RELEVANCE STATEMENT

Achieving the specific ablation range may improve local efficacy for early-stage non-small cell lung cancer located adjacent to the bronchovascular bundle.

KEY POINTS

• Local efficacy of percutaneous microwave ablation in treating early-stage non-small cell lung cancer was affected by bronchovascular bundle proximity. • Achieving the specific ablation range may improve local efficacy for lesions located adjacent to the bronchovascular bundle.

Association Between Coronavirus Disease 2019 Vaccination and Mortality After Major Operations

OBJECTIVE

The objective of this study was to compare postoperative 90-day mortality between (1) fully vaccinated patients with COVID-19-positive and negative diagnosis, and (2) vaccinated and unvaccinated patients with COVID-19 positive diagnosis.

BACKGROUND

Societal guidelines recommend postponing elective operations for at least 7 weeks in unvaccinated patients with preoperative coronavirus disease 2019 (COVID-19) infection. The role of vaccination in this infection-operation time risk is unclear.

METHODS

We conducted a national US multicenter retrospective, matched cohort study spanning July 2021 to October 2022. Participants were included if they underwent a high-risk general, vascular, orthopedic, neurosurgery, or genitourinary surgery. All-cause mortality occurring within 90 days of the index operation was the primary outcome. Inverse probability treatment weighted propensity scores were used to adjust logistic regression models examining the independent and interactive associations between mortality, exposure status, and infection proximity.

RESULTS

Of 3401 fully vaccinated patients in the 8-week preoperative period, 437 (12.9%) were COVID-19-positive. Unadjusted mortality rates were not significantly different between vaccinated patients with COVID-19 (22, 5.0%) and vaccinated patients without COVID-19 (99, 3.3%; P = 0.07). After inverse probability treatment weighted adjustment, mortality risk was not significantly different between vaccinated COVID-19-positive patients compared to vaccinated patients without COVID-19 (adjusted odds ratio = 1.38, 95% CI: 0.70, 2.72). The proximity of COVID-19 diagnosis to the index operation did not confer added mortality risk in either comparison cohort.

CONCLUSIONS

Contrary to risks observed among unvaccinated patients, postoperative mortality does not differ between patients with and without COVID-19 when vaccinated against the severe acute respiratory syndrome coronavirus 2 virus and receiving a high-risk operation within 8 weeks of the diagnosis, regardless of operation timing relative to diagnosis.

Application of machine learning algorithms in classifying postoperative success in metabolic bariatric surgery: Acomprehensive study

Objectives

Metabolic bariatric surgery is a critical intervention for patients living with obesity and related health issues. Accurate classification and prediction of patient outcomes are vital for optimizing treatment strategies. This study presents a novel machine learning approach to classify patients in the context of metabolic bariatric surgery, providing insights into the efficacy of different models and variable types.

Methods

Various machine learning models, including Gaussian Naive Bayes, Complement Naive Bayes, K-nearest neighbour, Decision Tree, K-nearest neighbour with RandomOverSampler, and K-nearest neighbour with SMOTE, were applied to a dataset of 73 patients. The dataset, comprising psychometric, socioeconomic, and analytical variables, was analyzed to determine the most efficient predictive model. The study also explored the impact of different variable groupings and oversampling techniques.

Results

Experimental results indicate average accuracy values as high as 66.7% for the best model. Enhanced versions of K-nearest neighbour and Decision Tree, along with variations of K-nearest neighbour such as RandomOverSampler and SMOTE, yielded the best results.

Conclusions

The study unveils a promising avenue for classifying patients in the realm of metabolic bariatric surgery. The results underscore the importance of selecting appropriate variables and employing diverse approaches to achieve optimal performance. The developed system holds potential as a tool to assist healthcare professionals in decision-making, thereby enhancing metabolic bariatric surgery outcomes. These findings lay the groundwork for future collaboration between hospitals and healthcare entities to improve patient care through the utilization of machine learning algorithms. Moreover, the findings suggest room for improvement, potentially achievable with a larger dataset and careful parameter tuning.

Prediction of Complications and Prognostication in Perioperative Medicine: A Systematic Review and PROBAST Assessment of Machine Learning Tools

BACKGROUND

The utilization of artificial intelligence and machine learning as diagnostic and predictive tools in perioperative medicine holds great promise. Indeed, many studies have been performed in recent years to explore the potential. The purpose of this systematic review is to assess the current state of machine learning in perioperative medicine, its utility in prediction of complications and prognostication, and limitations related to bias and validation.

METHODS

A multidisciplinary team of clinicians and engineers conducted a systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocol. Multiple databases were searched, including Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, PubMed, Medline, Embase, and Web of Science. The systematic review focused on study design, type of machine learning model used, validation techniques applied, and reported model performance on prediction of complications and prognostication. This review further classified outcomes and machine learning applications using an ad hoc classification system. The Prediction model Risk Of Bias Assessment Tool (PROBAST) was used to assess risk of bias and applicability of the studies.

RESULTS

A total of 103 studies were identified. The models reported in the literature were primarily based on single-center validations (75%), with only 13% being externally validated across multiple centers. Most of the mortality models demonstrated a limited ability to discriminate and classify effectively. The PROBAST assessment indicated a high risk of systematic errors in predicted outcomes and artificial intelligence or machine learning applications.

CONCLUSIONS

The findings indicate that the development of this field is still in its early stages. This systematic review indicates that application of machine learning in perioperative medicine is still at an early stage. While many studies suggest potential utility, several key challenges must be first overcome before their introduction into clinical practice.

EDITOR’S PERSPECTIVE

Minimally Invasive Robotic Techniques for Hepatocellular Carcinoma Resection: How I Do It

The adoption of minimally invasive techniques for hepatocellular resection has progressively increased in North America. Cumulative evidence has demonstrated improved surgical outcomes in patients who undergo minimally invasive hepatectomy. In this review, the authors' approach and methodology to minimally invasive robotic liver resection for hepatocellular carcinoma is discussed.

Predicting Mortality of COVID-19 in Kidney Transplant Recipients With Developed Scores

OBJECTIVES

COVID-19 is a recently discovered β-subtype coronavirus infection due to SARS-CoV-2. Approximately 20% of COVID-19 patients have moderate to severe clinical manifestations and 5% progress to critical illness. Kidney transplant patients form a special group. In our study, we aimed to evaluate the success of the COVID-gram score and systemic immuno-inflammation index score in predicting the risk of mortality during hospitalization among kidney transplant patients.

MATERIALS AND METHODS

Our study included 50 kidney transplant patients with positive real-time reverse transcription polymerase chain reaction COVID-19 tests between March 2020 and March 2021. Risk scores were calculated using baseline clinical data collected retrospectively from the patient cohort.

RESULTS

The mean age was 54.3 ± 10.2. The mortality rate was 12%. When we compared the COVID-gram and systemic immuno-inflammation index scores between survivors and nonsurvivors, we did not find any difference.

CONCLUSIONS

Kidney and other solid-organ transplant patients are at greater risk of infection and mortality than other groups. Accurate risk-predicting tools are imperative for managing the COVID-19 pandemic with limited health resources.

Surgery for Recurrent Epithelial Ovarian Cancer

PURPOSE OF REVIEW

To review evidence around the value and challenges of surgery for recurrent epithelial ovarian cancer (ROC). Both cytoreductive and palliative aspects will be addressed RECENT FINDINGS: Prospective and retrospective evidence demonstrates a significantly longer remission derived from the combination of surgical and systemic modalities as opposed to systemic treatment alone in carefully selected ROC-patients who have relapsed more than 6 months from the end of their 1st line platinum-based chemotherapy. Nevertheless, this benefit appears to be limited when total macroscopic tumor clearance is not achieved. Selection algorithms to identify optimal surgical candidates are of paramount importance to prevent surgical morbidity without the equivalent oncological benefit. In the palliative setting, the risks and benefits of salvage surgery need to be counterbalanced with the advances of conservative techniques for optimal care. Well-defined selection algorithms to identify those who will benefit from surgery in the relapsed setting appear to be the key to oncologic and surgical success.

Changes in Patterns of Referral for Inpatient Rehabilitation Cancer Patients Due to COVID-19: A Retrospective Study

ABSTRACT

There is a paucity of literature on the effect of COVID-19 on hospital processes. We hypothesized that COVID-19 was associated with decreased cancer physiatry referrals in 2020. This is a retrospective cohort study of consecutive patients from April to July 2019 and 2020 admitted at an academic quaternary cancer center. The main outcomes were number of hospital admissions, rate, and characteristics of inpatient rehabilitation admissions and change in percentage of physiatry referrals as the primary endpoint. Results showed that in 2019, there were 387 referrals from 10,274 inpatient admissions (3.8%; 95% confidence interval, 2.4-4.2), compared with 337 referrals from 7051 admissions in 2020 (4.8%; 95% confidence interval, 4.3-5.3, P = 0.001). Hematology services referred more patients than neurosurgery in 2020 (20.4% vs. 31.4%; 48.2% vs. 26.5%, P = 0.01). Discharge disposition reflected an increased frequency of return to acute care service in 2020 (10.2% vs. 21.8%, P = 0.03). In conclusion, there was an increase in the rate of physiatry referrals despite a decrease in hospital admissions. There was an increase in referrals by hematology, likely due to emphasis on safe discharge and the populations hospitalized.

Thoracic delirium index for predicting postoperative delirium in elderly patients following thoracic surgery: A retrospective case-control study

BACKGROUND

Postoperative delirium (POD) is an acute neurological complication in the elderly undergoing thoracic surgery and can result in serious adverse consequences.

AIMS

This study aimed to identify the related risk factors for POD following thoracic surgery, primarily focusing on preoperative serum biomarkers, and further to establish a novel delirium index to better predict POD.

METHODS

A total of 279 patients aged ≥60 years who underwent elective thoracic surgery from August 2021 to August 2022 were enrolled in this observational study. The platelet-to-white blood cell ratio (PWR) was calculated as number the of platelets divided by the number of white blood cells. POD was defined by the confusion assessment method twice daily during the postoperative first 3 days. Multivariate regression analysis was performed to identify all potential variables for POD. Moreover, a novel thoracic delirium index (TDI) was developed based on the related risk factors. The accuracy of TDI and its component factors in predicting POD was determined by the curve of receiver operating characteristic (ROC).

RESULTS

In total, 25 of 279 patients developed POD (8.96%). Age, PWR, and average pain scores within the first 3 days after surgery were regarded as the independent risk factors for POD. Moreover, the ROC analysis showed the TDI, including age, PWR, and average pain scores within the first 3 days after surgery, can more accurately predict POD with the largest area under the curve of 0.790 and the optimal cutoff value of 9.072, respectively.

CONCLUSION

The TDI can scientifically and effectively predict POD to provide optimal clinical guidance for older patients after thoracic surgery.

Evaluation of learning curve with Indocyanine Green (IcG) versus blue dye for sentinel lymph node biopsy in breast cancer

BACKGROUND

Indocyanine green (IcG) is an alternative to isosulfan blue (IB) for sentinel lymph node (SLN) mapping in breast cancer (BC). IcG carries improved cost and safety, but oncologic data upon implementation in practice is limited. We evaluated the learning curve defined as oncologic yield and operative (OR) time for IcG in SLN mapping in BC.

METHODS

Retrospective review of patients >18 years with cTis-2 cN0 BC undergoing surgery first with SLN biopsy using IB or IcG. Analysis compared IB versus IcG across three time cohorts.

RESULTS

Of 278 patients, 77 received IB and 201 received IcG. OR time was longer for IcG (p ​= ​0.022). There was no difference in oncologic yield between groups (p ​= ​0.35, p ​= ​0.61).

CONCLUSIONS

Surgeons may be able to safely transition from IB to IcG for patients with early-stage breast cancer undergoing surgery first. Individuals should track their own data to confirm safety of the technique.

Radiomics-based machine learning and deep learning to predict serosal involvement in gallbladder cancer

OBJECTIVE

Our study aimed to determine whether radiomics models based on contrast-enhanced computed tomography (CECT) have considerable ability to predict serosal involvement in gallbladder cancer (GBC) patients.

MATERIALS AND METHODS

A total of 152 patients diagnosed with GBC were retrospectively enrolled and divided into the serosal involvement group and no serosal involvement group according to paraffin pathology results. The regions of interest (ROIs) in the lesion on all CT images were drawn by two radiologists using ITK-SNAP software (version 3.8.0). A total of 412 features were extracted from the CT images of each patient. The Mann‒Whitney U test was applied to identify features with significant differences between groups. Seven machine learning algorithms and a deep learning model based on fully connected neural networks (f-CNNs) were used for radiomics model construction. The prediction efficacy of the models was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Through the Mann‒Whitney U test, 75 of the 412 features extracted from the CT images of patients were significantly different between groups (P < 0.05). Among all the algorithms, logistic regression achieved the highest performance with an area under the curve (AUC) of 0.944 (sensitivity 0.889, specificity 0.8); the f-CNN deep learning model had an AUC of 0.916, and the model showed high predictive power for serosal involvement, with a sensitivity of 0.733 and a specificity of 0.801.

CONCLUSION

Radiomics models based on features derived from CECT showed convincing performances in predicting serosal involvement in GBC.

A review and metanalysis of metronomic oral single-agent cyclophosphamide for treating advanced ovarian carcinoma in the era of precision medicine

OBJECTIVE

Oral metronomic cyclophosphamide has been used as a single agent or in combination with other drugs for several solid tumors with interesting results in disease palliation and mild to moderate toxicity, notably in patients with recurrent epithelial ovarian cancer (EOC) progressing after systemic chemotherapy. In this paper, we report a review and a metanalysis of heterogeneous data published up to date.

DATA SOURCES

The literature search was restricted to single-agent MOC. The analysis was conducted through March 2023 by consulting PubMed, Embase, Google Scholar, and The Cochrane Library databases. Research string and Medical Subject Headings included "ovarian tumor," "ovarian carcinoma," or "ovarian cancer," "fallopian tube cancer," "primary peritoneal cancer," "oral chemotherapy," and "metronomic cyclophosphamide." All articles were assessed for quality by at least two investigators independently, and a < 18 patients sample size cutoff was chosen as a lower limit with a Cohen's kappa statistical coefficient for accuracy and reliability. Metanalysis of selected papers was carried out according to a fixed model.

DATA SUMMARY

The percentage of agreement between investigators on literature study selection was very high, reaching 96.9% with a Cohen's k of 0.929. MOC pooled objective response rate (ORR) and disease control rate for recurrent or platinum-refractory ovarian cancer were 18.8% (range 4-44%) and 36.2% (range 16-58.8%), respectively. The mean progressive-free survival and overall survival were 3.16 months (range 1.9 to 5.0 months) and 8.7 months (range 8 to 13 months), respectively. The fixed model metanalysis of selected studies showed a 16% median ORR (12-20% CI, p < 0.001).

CONCLUSIONS

Single-agent oral cyclophosphamide in EOC holds promise as a treatment option, even in the era of precision medicine. Genetic factors, such as DNA repair gene polymorphisms, may influence treatment response. Combining cyclophosphamide with biological agents such as PARP inhibitors or immunotherapy agents is an area of active investigation.