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Yi Gao1 *, Xuezhao Chen2 *, Qi Zhou,1,3 Jiannan Song,1,3 Xizhe Zhang,1,3 Yi Sun,1,3 Miao Yu,1,3 Yun Li1,3 1Chifeng Clinical Medical College of Inner Mongolia Medical University, Chifeng, People’s Republic of China; 2First Hospital of Shanxi Medical University, Taiyuan, People’s Republic of China; 3Department of Anesthesiology, Chifeng Municipal Hospital, Chifeng, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yun Li, Chifeng Municipal Hospital, Hongshan, Chifeng, Inner Mongolia Autonomous Region, People’s Republic of China, Tel +86 188 4760 0734, Email cfsyy_liyun@126.comPurpose: Perioperative sleep disorders have attracted much attention due to their high prevalence and severe harm, and the current treatment methods are insufficient. Some randomized controlled trials (RCTs) have produced controversial results on whether melatonin can improve perioperative sleep quality. This review aimed to evaluate the effects of melatonin treatment on perioperative sleep quality.Patients and Methods: A systematic search of six databases was performed to identify RCTs investigating melatonin and perioperative sleep. The outcomes analyzed were subjective sleep quality, sleep latency (SL), total sleep time (TST), sleep efficiency (SE), the behavior of awakenings and daily naps, and the incidence of poor sleep quality. RevMan 5.4 and Stata 16 software was used for the meta-analysis and sensitivity analysis, and trial sequential analysis was conducted using TSA 0.9.5.10 Beta software. This study was registered in PROSPERO (registration number: CRD42022311378).Results: 10 studies containing 725 participants were included. Melatonin improved postoperative subjective sleep quality (SMD: − 0.30; 95% CI: [− 0.47, − 0.14]; P = 0.0004) but not preoperative sleep quality (MD: − 2.76; 95% CI: [− 10.44, 4.91]; P = 0.48). In the postoperative period, 6mg dose had the best efficacy (SMD: − 0.31; 95% CI: [− 0.57, − 0.04]; P = 0.02). Melatonin increased postoperative TST (P = 0.02) and SE (P = 0.002) and decreased the incidence of postoperative poor sleep quality (P = 0.002) but had no effect on SL (P = 0.11), the number and duration of awakenings (P = 0.28; P=0.55), and the number and duration of daily naps (P = 0.26; P = 0.38). The trial sequential analysis showed that the accumulated Z value crossed both the traditional boundary value and the TSA boundary value, further confirming the stability of the result of the meta-analysis.Conclusion: Melatonin treatment can improve postoperative sleep quality. A 6mg daily dose of melatonin may have a better beneficial effect, which needs further exploration. This study supports the application of melatonin for improving postoperative sleep quality.Keywords: melatonin, sleep quality, perioperative, preoperative, postoperative, meta-analysis

Abstract Background To investigate the association between the level of glycosylated hemoglobin (HbA1c) and preoperative deep vein thrombosis (DVT) and that between diabetes mellitus (DM) and preoperative DVT in patient undergoing total joint arthroplasty (TJA). Methods A total of 1386 patients were enrolled. We created the receiver operating characteristic (ROC) curve of HbA1c, and based on the cutoff value, patients were divided into two groups. Risk factors were subsequently examined. Chi-square test or Fisher’s exact test was adopted for enumeration data. The results were expressed in percentages (%), and DVT-related variates were analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis and calculated the adjusted odds ratio (OR) and 95% confidence interval (95% CI). Results Preoperative DVT was 100 cases (7.22%) and DM in 301 cases (21.7%). We determined the cutoff value of HbA1c of 6.15% using the ROC curve as the area under the curve (AUC) was 0.548. Univariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM, female, and major surgery in the last 12 months increased by 1.84 (P = 0.005; 95% CI [1.20–2.80]), 2.22 (P = 0.028, 95% CI [1.09–4.52]), 2.47 (P = 0.013, 95% CI [1.21–5.04]), 2.03 (P = 0.004, 95% CI [1.25–3.30]); 1.85 (P = 0.010, 95% CI [1.16–2.95]); and 2.86 times (P = 0.006, 95% CI [1.35–6.05]), respectively. And multivariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM patients, female patients, and major surgery in the last 12 months increased by 1.77 (P = 0.009, 95% CI [1.16–2.72]); 2.10 (P = 0.043, 95% CI [1.02–4.30]); 2.50 (P = 0.013, 95% CI [1.22–5.14]); 2.01 (P = 0.005, 95% CI [1.23–3.28]); 1.80 (P = 0.014, 95% CI [1.13–2.89]); and 3.04 times (P = 0.004, 95% CI [1.42–6.49]), respectively. Conclusion We conclude that HbA1c ≥ 6.15%, DM, female and major surgery in the last 12 months are the independent risk factors for preoperative DVT in patients undergoing TJA. And patients with a higher HbA1c level are at an increased risk of preoperative DVT. Trial registration: ChiCRT2100054844.

Abstract Background There are currently no scoring-type predictive models using only easily available pre- and intraoperative data developed for assessment of the risk of advanced axillary lymph node metastasis (ALNM) in patients with breast cancer with metastatic sentinel lymph nodes (SLNs). We aimed to develop and validate a scoring system using only pre- and intraoperative data to distinguish between non-advanced (≤ 3 lymph nodes) and advanced (> 3 lymph nodes) ALNM in patients with breast cancer with metastatic SLNs. Methods We retrospectively identified 804 patients with breast cancer (cT1-3cN0) who had metastatic SLNs and had undergone axillary lymph node dissection (ALND). We evaluated the risk factors for advanced ALNM using logistic regression analysis and developed and validated a scoring system for the prediction of ALNM using training (n = 501) and validation (n = 303) cohorts, respectively. The predictive performance was assessed using the receiver operating characteristic (ROC) curve, area under the curve (AUC), and calibration plots. Results Ultrasound findings of multiple suspicious lymph nodes, SLN macrometastasis, the ratio of metastatic SLNs to the total number of SLNs removed, and the number of metastatic SLNs were significant risk factors for advanced ALNM. Clinical tumor size and invasive lobular carcinoma were of borderline significance. The scoring system based on these six variables yielded high AUCs (0.90 [training] and 0.89 [validation]). The calibration plots of frequency compared to the predicted probability showed slopes of 1.00 (training) and 0.85 (validation), with goodness-of-fit for the model. When the cutoff score was set at 4, the negative predictive values (NPVs) of excluding patients with advanced ALNM were 96.8% (training) and 96.9% (validation). The AUC for predicting advanced ALNM using our scoring system was significantly higher than that predicted by a single independent predictor, such as the number of positive SLNs or the proportion of positive SLNs. Similarly, our scoring system also showed good discrimination and calibration ability when the analysis was restricted to patients with one or two SLN metastases. Conclusion Our easy-to-use scoring system can exclude advanced ALNM with high NPVs. It may contribute to reducing the risk of undertreatment with adjuvant therapies in patients with metastatic SLNs, even if ALND is omitted.

Background: There is a paucity of data regarding the prevalence of preoperative deep vein thrombosis (DVT) in patients with long bone (including femur, tibia and fibula) fractures of the lower limbs. We performed a meta-analysis to address the issue. Methods: Electronic databases, including PubMed, EMBASE, the Web of Science, the Cochrane Library, the VIP database, CNKI, and the Wanfang database, were systematic searched for original articles that reported the prevalence of preoperative DVT in long bone fractures of the lower limbs from January 2016 to September 2021. The prevalence of preoperative DVT was pooled using random-effects models, and subgroups were established according to study type, detection method, sample size and fracture site. Results: Twenty-three articles reporting on 18,119 patients were eligible. The overall pooled preoperative DVT prevalence was 24.1% (95% CI 19.3–28.8%). In different subgroups, the preoperative DVT prevalences were 18.2–27.3%, 15.2–28.6%, 23.1–24.9%, 18.2–26.0% and 23.2–23.4% for different study designs, sample sizes, age groups, detection methods and fracture sites, respectively. Conclusions: Despite the heterogeneity among studies, this systematic review suggests that the prevalence of preoperative DVT, which may seriously affect the prognosis of patients, is high. Therefore, greater efforts should be devoted to the improvement of screening and prevention strategies for preoperative DVT in lower-extremity long bone fractures. Level of Evidence: Level III. Trial Registration The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database with the registration number CRD42022324706. [ABSTRACT FROM AUTHOR]

Simple Summary: Musculoskeletal tumors often require surgical treatment, which can result in substantial peri-operative blood loss. Preoperative transarterial embolization (TAE) is used to reduce peri-operative blood loss during the surgery of musculoskeletal tumors but there is no consensus about the actual place of TAE in the musculoskeletal tumor therapeutic algorithm, and there is no firm recommendation about its best technical approach. The purpose of this study was to report our experience in preoperative TAE of musculoskeletal tumors regarding the effectiveness of preoperative TAE in terms of blood loss and functional outcomes. For 31 patients, we found that TAE led to complete (58%) or near-complete (42%) tumor devascularization, allowing bloodless surgery in 71% of patients and moderate transfusion needs for the remaining 29%. A total of 27% of patients had complete improvement of the initial symptoms at the end of the follow-up, 15 (50%) with partially satisfying improvement, 4 (13%) with partially unsatisfying improvement and 3 (10%) with no improvement. The purpose of this study was to report the effectiveness of preoperative transcatheter arterial embolization (TAE) of musculoskeletal tumors in terms of blood loss and functional outcomes. Patients who underwent preoperative TAE of hypervascular musculoskeletal tumors between January 2018 and December 2021 were retrospectively included. The patients' characteristics, TAE procedure details, degree of post-TAE devascularization, surgical outcomes in terms of red blood cell transfusion and functional results were collected. The degree of devascularization was compared between patients who had peri-operative transfusion and those who did not. Thirty-one patients were included. The 31 TAE procedures led to complete (58%) or near-complete (42%) tumor devascularization. Twenty-two patients (71%) had no blood transfusion during surgery. Nine patients (29%) had a blood transfusion, with a median number of red blood cell packs of three (q1, 2; q3, 4; range: 1–4). Eight patients (27%) had complete improvement of the initial musculoskeletal symptoms at the end of the follow-up, 15 (50%) had partially satisfying improvement, 4 (13%) had partially unsatisfying improvement and 3 (10%) had no improvement. Our study suggests that preoperative TAE of hypervascular musculoskeletal tumors allowed for bloodless surgery in 71% of patients and minimal transfusion needs for the remaining 29%. [ABSTRACT FROM AUTHOR]

Infectious complications following bowel surgery continues to be a leading cause of postoperative morbidity. Both patient- and procedure-related factors contribute to risk. Compliance with evidence-based process measures is the best strategy for prevention of surgical site infections. Three process measures that aim to reduce the bacterial load present at the time of surgery are mechanical bowel preparation, oral antibiotics, and chlorhexidine bathing. There is heightened awareness of surgical site infections, in part due to improved access to reliable postoperative complication data for colon surgery as well as incorporation of surgical site infection into public reporting and pay-for-performance payment models. As a result, the literature has improved with regard to the effectiveness of these methods in reducing infectious complications. Herein, we provide the evidence to support adoption of these practices into colorectal surgery infection prevention programs. [ABSTRACT FROM AUTHOR]

Background: Three‐dimensional (3D) contrast‐enhanced T1‐weighted flow‐sensitive black‐blood (CE‐T1WI FSBB) is a newly developed black blood sequence by adding motion probing gradient pulses to gradient echo (GRE) sequences, which has important value for the preoperative assessment of tumor brain blood supply vessels and intratumoral microbleeds. Purpose: To compare 3D CE‐T1WI FSBB and 3D contrast‐enhanced fast spin echo (FSE) sequence for T1WI for preoperative assessment of blood vessels and microbleeds in brain tumors and to investigate the correlation between visible vessels and microbleeds. Study type: Prospective. Subjects: One hundred and seventy‐five patients with brain tumors, 65 were male, 110 were female. Including histologically confirmed 73 meningiomas, 23 schwannomas, 20 gliomas, 7 hemangioblastomas, 5 metastases, 2 lymphomas, 2 hemangiopericytomas, 2 germ cell tumors, 1 craniopharyngioma, and 1 cholesteatoma. Field Strength/Sequence: A 3‐T, CE‐T1WI FSBB, GRE; 3‐T, CE‐T1WI, FSE. Assessment: Three neuroradiologists counted the number of intratumoral vessels on CE‐T1WI and CE‐T1WI FSBB images separately, and they counted the number of intratumoral microbleeds on CE‐T1WI FSBB images. Brain tumors were classified into grade I, grade II, and grade IV according to the World Health Organization (WHO) grading. Differences in the ability of CE‐T1WI FSBB and CE‐T1WI to display intratumoral vessels were compared. The mean counts of three observers were used to study the correlation between vessels and microbleeds. Statistical Tests: Two‐way random intraclass correlation coeficient (ICC) was used for inter‐reader agreement regarding intratumoral vessel and microbleed counts, and the linear regression analysis (with F‐test) was used to study the correlation between intratumoral vessels and microbleeds based on CE‐T1WI FSBB (α = 0.05). Results: Inter‐reader agreements for intratumoral vessel count on CE‐T1WI (ICC = 0.93) and CE‐T1WI FSBB (ICC = 0.92), and the agreement for intratumoral microbleed count on CE‐T1WI FSBB (ICC = 0.99) were excellent. There were statistically significant differences in intratumoral vessel counts between CE‐T1WI and CE‐T1WI FSBB using Mann–Whitney U ‐test: image readers could identify more intratumoral vessels on CE‐T1WI FSBB images, particularly for meningiomas, schwannomas, gliomas, and WHO grade I tumors. The number of intratumoral vessels had a significant positive effect on the number of intratumoral microbleeds (microbleeds = 5.024 + 1.665 × vessels; F = 11.51). Data Conclusion: More intratumoral vessels could potentially be identified using a 3D CE‐T1WI FSBB sequence compared to a CE‐T1WI sequence, and the number of intratumoral vessels showed a positive linear relationship with the number of intratumoral microbleeds, which might suggest that brain tumors with rich blood supply were more prone to intratumoral microbleeds. Evidence Level: 2 Technical Efficacy: Stage 3 [ABSTRACT FROM AUTHOR]

Background: This research focuses on the relationship between the changes in peripheral blood eosinophils (PBEs) perioperatively and the prognosis of lung cancer. Methods: The study included 414 lung cancer patients. These patients were divided into the DOWN (186 patients) and UP (209 patients) groups according to perioperative changes in PBEs. Furthermore, overall survival was compared based on pathological stage, pathological type, tumor location, age and sex. Furthermore, the authors analyzed the prediction of PBEs on the prognosis of chemotherapy. Results: The results showed that lung cancer patients in the DOWN group had a better prognosis (p = 0.0121; 95% CI: 0.6915 [0.5184–0.9224]), and the DOWN group patients with normal postoperative PBEs had a better prognosis (p = 0.0115; 95% CI: 0.6721 [0.4938–0.9148]). Conclusion: Lung cancer patients whose postoperative PBEs were lower than preoperative PBEs had a better prognosis. [ABSTRACT FROM AUTHOR]

Mounting evidence suggests that recovery begins before the surgical incision. The presurgery phase of recovery, namely the preparation for optimal surgical recovery, can be reinforced with prehabilitation. Prehabilitation is the approach of enhancing the functional capacity of the individual to enable them to withstand a stressful event. With this narrative review, we apply the Wilson and Cleary conceptual model of patient outcomes to specify the complex and integrative relationship of health factors that limit functional capacity before surgery. To have the greatest impact on patient outcomes, prehabilitation programs require individualised and coordinated care from medical, nutritional, psychosocial and exercise services. Key points: 1.Many biological and physiological factors influence functional capacity.2.Some of the biological and physiological factors that limit function cannot be corrected with exercise alone.3.Prehabilitation programs that identify and address the root cause(s) for poor functional capacity with multimodal treatment may produce positive outcomes more consistently. [ABSTRACT FROM AUTHOR]

Introduction: Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial. Methods and procedures: We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings. Results: Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs. Conclusion: Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery. [ABSTRACT FROM AUTHOR]

Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated. Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0–10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed. Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11–50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; –11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery (p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant. Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome. [ABSTRACT FROM AUTHOR]

Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use. The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes. The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including "preoperative" AND "patient education" AND "elective surgery," limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded. From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety. Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery. [ABSTRACT FROM AUTHOR]

PURPOSES: To evaluate the application of contrast enhanced ultrasound (CEUS) in preoperatively differential diagnosis between pancreatic solid pseudopapillary tumors (SPTs) and pancreatic neuroendocrine tumors (pNETs). PATIENTS AND METHODS: This retrospective study was approved by Institutional Review Board. Patients with surgical resection and histopathological diagnosis as SPTs and pNETs were included. All patients underwent B mode ultrasound (BMUS) and CEUS examinations within one week before surgical operation. On BMUS, the size, location, echogenicity, calcification, and margin of lesions were observed and recorded. On CEUS imaging, enhancement patterns, and enhancement degrees were recorded and analyzed. An independent t-test or Mann-Whitney U test was used for comparison between continuous variables. Chi-square test was used to compare the CEUS patterns. RESULTS: From February 2017 to Dec 2022, patients diagnosed as SPTs (n = 39) and pNETs (n = 48) were retrospectively included. On BMUS, anechoic cystic changes (19/39, 48.72%) and hyperechoic calcification (14/39, 35.90%) are more commonly detected in SPTs (P = 0.000). On CEUS imaging, the majority of SPTs (27/39, 69.23%) showed hypo-enhancement in the arterial phase, while most of the pNETs (36/48, 75.00%) showed hyper- or iso-enhancement in the arterial phase (P = 0.000). In the venous phase, most of the SPTs (32/39, 82.05%) showed hypo-enhancement, while over half of pNETs (29/48, 60.42%) showed hyper- or iso-enhancement compared to pancreatic parenchyma (P = 0.001). CONCLUSIONS: CEUS is a valuable and non-invasive imaging method to make preoperatively differential diagnoses between SPTs and pNETs. [ABSTRACT FROM AUTHOR]

To determine the feasibility, safety and preliminary effectiveness of preoperative functional high-intensity interval training (f-HIIT) for high-risk patients undergoing LSF. High-risk patients eligible for elective 1–3 level LSF were included. Feasibility and safety of the preoperative f-HIIT program was determined by measuring participation and attrition rates, training adherence, adverse events, reached training intensity and preoperative progression in physical fitness. Preliminary effect of the preoperative f-HIIT program was estimated on time to postoperative functional recovery and length of hospital stay (LoS) between high-risk patients who did and did not participate in the prehabilitation program. Eleven out of 23 high-risk patients opted to participate in the f-HIIT program, which was safe and feasible, as no adverse events occurred and only one out of 74 sessions was missed (1.4%). Trained high-risk patients improved their physical fitness with 21.2% on average and obtained faster time to functional recovery compared to matched untrained patients (median 4.5 vs 7.5 days; p = 0.013). No effect was seen on LoS (median 7 vs 8 days (p = 0.58)). The preoperative f-HIIT program is feasible, safe and shortened time to postoperative functional recovery in patients who underwent LSF. Preoperative high-intensity interval training is safe and feasible for high-risk patients opting for lumbar spinal fusion. In a relatively small sample the study shows preoperative high-intensity interval training could reduce time to functional recovery in high-risk patients opting for lumbar spinal fusion. [ABSTRACT FROM AUTHOR]

Introduction: Complex eventration produce great defects on the abdominal wall whose repair means a great challenge. A correct planning with patients is needed in order to tackle this defect with success. Progressive preoperative pneumoperitoneum as a therapeutic tool to prepare these patients has improved the results of this surgery and reduced complications. Objective: The aim of this study is to demonstrate the efficacy of the pre-surgery preparation with pneumoperitoneum (PPP) as a complement to surgical reparation of the complex eventrations. Material and methods: Retrospective study of 24 patients with complex eventration, within April 2018 and January 2020, previously chosen to pre-surgery infiltration of pneumoperitoneum and that afterwards had the corresponding technique of surgical reparation applied. Results: Of all the studied cases, derived complications of using the PPP were almost inexistent and it was well tolerated by patients. The preparation with this technique took place throughout approximately 12 days before surgery and the amount of air provided was about 7,979 cm3. With that, the rise of the intraabdominal pressure after surgery is minimum, keeping it in optimal levels and decreasing possible complications. The correct application of this tool, the employed surgical techniques (TAR or Rives-Stoppa) and the use of prosthetic material have facilitated the success of the eventration’s repair. Conclusions: The PPP has turned out to be a safe and useful therapeutic tool to deal these kind of abdominal wall defects. Its issues are almost non-existent and it means a great advantage in the eventration’s surgery. [ABSTRACT FROM AUTHOR]

Background: Placenta previa is a common cause of postpartum hemorrhage (PPH) that contributes substantively to maternal morbidity and mortality rates. Tranexamic acid is an antifibrinolytic drug that is useful for the treatment of PPH. The recommendation from many guidelines is to start giving tranexamic acid as soon as PPH is diagnosed to reduce postpartum blood loss. Furthermore, some studies report the beneficial use of tranexamic acid given as a prophylactic before Cesarean section to decrease intraoperative blood loss and prevent PPH. To the authors' knowledge, in high-risk obstetrics case such as placenta previa, there was insufficient data to support recommendations of the use of tranexamic acid for prevent PPH. Objective: To evaluate the efficacy of supplementary intravenous tranexamic acid before cesarean section versus prophylactic intravenous oxytocin after placenta delivery alone to decrease intraoperative blood loss and prevent PPH in placenta previa. Material and Methods: The present study conducted a double blinded placebo control trial comparing adjunct 1 g tranexamic acid given intravenously before skin incision with prophylactic intravenous oxytocin after placenta delivery alone before cesarean section for placenta previa. The study recruited 60 women who were diagnosed with placenta previa at gestational age (GA) of more than 28 completed weeks undergoing emergency cesarean section due to active bleeding or scheduled for elective cesarean section at 37 completed weeks at Chonburi Hospital between July 2021 and July 2022. The primary outcome was intraoperative blood loss. Results: Sixty diagnosed placenta previa women were recruited, with 30 patients per group. Group I patients were given 1 g tranexamic acid and Group II were given a placebo of 100 ml NSS before skin incision. Both groups received intravenous oxytocin 20 units after placenta delivery. The main outcome showed that preoperative tranexamic acid intravenous reduced intraoperative blood loss significantly compared with the placebo at 349.5 ml (range of 168 to 2,200) versus 619 ml (range of 288 to 3,243), p<0.001. The secondary outcome showed a significant decrease in the incidence of PPH at 4 (13.33%) versus 10 (33.33%), p=0.030 and decreased in the incidence of blood transfusion of more than one unit from 5 (16.67%) versus 13 (43.33%), p=0.047. Conclusion: Prophylactic supplementary 1 g tranexamic acid intravenously before cesarean section to prophylactic intravenous oxytocin after placental delivery was found to effectively reduce intraoperative blood loss and PPH. [ABSTRACT FROM AUTHOR]

Abstract Background Growing evidences have indicated neurodevelopmental disorders in infantile esotropia (IE). However, few studies have analyzed the characteristics of large‐scale functional networks of IE patients or their postoperative network‐level alterations. Methods Here, individuals with IE (n = 32) and healthy subjects (n = 30) accomplished the baseline clinical examinations and resting‐state MRI scans. A total of 17 IE patients also underwent corrective surgeries and completed the longitudinal clinical assessments and resting‐state MRI scans. Linear mixed effects models were applied for cross‐sectional and longitudinal network‐level analyses. Correlation analysis was performed to assess the relationship between longitudinal functional connectivity (FC) alterations and baseline clinical variables. Results In cross‐sectional analyses, network‐level FC were apparently aberrant in IE patients compared to controls. In longitudinal analyses, intra‐ and internetwork connectivity were observed with significant alterations in postoperative IE patients compared to the preoperative counterparts. Longitudinal FC changes are negatively correlated to the age at surgery in IE. Conclusions Obviously, altered network‐level FC benefiting from the corrective surgery serves as the neurobiological substrate of the observed improvement of stereovision, visuomotor coordination, and emotional management in postoperative IE patients. Corrective surgery should be performed as early as possible to obtain more benefits for IE in brain function recovery.

ABSTRACTBackground Recent studies have shown that preoperative education can positively impact postoperative recovery, improving postoperative pain management and patient satisfaction. Gaps in preoperative education regarding postoperative pain and opioid use may lead to increased patient anxiety and persistent postoperative opioid use.Objectives The objective of this narrative review was to identify, examine, and summarize the available evidence on the use and effectiveness of preoperative educational interventions with respect to postoperative outcomes.Method The current narrative review focused on studies that assessed the impact of preoperative educational interventions on postoperative pain, opioid use, and psychological outcomes. The search strategy used concept blocks including “preoperative” AND “patient education” AND “elective surgery,” limited to the English language, humans, and adults, using the MEDLINE ALL database. Studies reporting on preoperative educational interventions that included postoperative outcomes were included. Studies reporting on enhanced recovery after surgery protocols were excluded.Results From a total of 761 retrieved articles, 721 were screened in full and 34 met criteria for inclusion. Of 12 studies that assessed the impact of preoperative educational interventions on postoperative pain, 5 reported a benefit for pain reduction. Eight studies examined postoperative opioid use, and all found a significant reduction in opioid consumption after preoperative education. Twenty-four studies reported on postoperative psychological outcomes, and 20 of these showed benefits of preoperative education, especially on postoperative anxiety.Conclusion Preoperative patient education interventions demonstrate promise for improving postoperative outcomes. Preoperative education programs should become a prerequisite and an available resource for all patients undergoing elective surgery.

Background: Neurocognitive function (NCF) before surgery is an important marker of baseline performance in patients with brain tumors. Increasingly, neurocognitive deficits (NCD) have been demonstrated in a high proportion of patients. Selection bias (patient, tumor, and surgical procedure related) may influence the prevalence and type of domains involved in patients with gliomas. Methods: We evaluated baseline NCF in a consecutive cohort of intra-axial tumors in Indian patients (n = 142). A comprehensive battery evaluating five domains – attention & executive function (EF), memory, language, visuospatial function and visuomotor abilities was used. Deficits were categorized as severe and mild-moderate. Factors associated with severe NCD were evaluated. Results: Severe NCD was present in 90% of the patients, 70% of them having affection of at least 2 domains. Attention-EF, memory and visuomotor speed were most affected. 132 underwent surgery (69 awake, 63 under general anesthesia - GA). The awake cohort had younger patients with lower grade gliomas and more left sided tumors. Multi-domain dysfunction was seen almost equally in awake/GA groups as well as left/right sided tumors. On multivariate analysis, older age, lower educational status and larger tumor volume adversely affected NCF in many of the domains. Only language dysfunction was location specific (temporal lobe tumors) though not laterality (left/right) specific. Conclusions: NCD were seen in a large majority of cases before surgery, including those undergoing awake surgery. Language may be affected even in tumors in the non-dominant hemisphere. Attention-EF and memory are most affected and need to be factored in while assessing patient performance intraoperatively during awake surgery as well as tailoring rehabilitative measures subsequently.

Introduction: Any major surgery like lower uterine Caesarean Section (CS) can be hazardous due to postoperative nosocomial infection. Pregnant mothers are at greater risk during such surgical intervention as compared to vaginal delivery. Prophylactic antibiotic administration is a standard practice across the globe to prevent such anticipated postoperative infection. Aim: To evaluate the prophylactic antimicrobial use with regards to the choice of antimicrobials, dose, route, timing and duration, any possible Adverse Drug Reaction (ADR) as well as to assess the frequency of the postoperative morbidity due to infection (if any). Materials and Methods: A prospective observational data-based study was conducted in the Department of Pharmacology in collaboration with Department of Obstetrics and Gynaecology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India, from February 2016 to October 2017. Study was conducted on 1944 pregnant women of reproductive age group planned or scheduled for elective/emergency lower segment CS, but otherwise healthy and received prophylactic antimicrobials for the surgery. They were prospectively observed regarding the treatment they received with focus on antimicrobial agents from the period of antimicrobial prophylaxis during their stay at hospital to till their discharge. Demographic data, vital signs, indication of CS, postoperative infections and ADR if any were recorded in predesigned proforma. The study population was divided into two groups: group A included 995 mothers, who received ceftriaxone sodium (1 g intravenously) and metronidazole (15 mg/kg) infusion and group B included 949 mothers, who received ampicillin (2 g intravenously), metronidazole (15 mg/kg) infusion and injection gentamycin (5 mg/kg) for 0.5 hour before initiation of CS. The data were statistically analysed by standard statistical software Microsoft Excel 2010 and Statistical Package for the Social Sciences (SPSS) sotware version 27.0 (SPSS Inc., Chicago, IL, USA) expressed as mean and standard deviation and percentage. Independent t- test and Chi-square test were used for analysis. Results: The mean age of group A was 22.36±3.07 years and group B was 22.76±2.47 years. Endomyometritis was documented in 4 (0.4%) from group A and 2 (0.21%) from the group B. Wound infection was present in 3 (0.3%) for group A and five (0.5%) for the group B. Infection related complications like chest infection seen in 7 (0.7%) for group A and in 3 (0.31%) for group B and urinary tract infection was noticed in 6 (0.6%) for group A and 5 (0.52%) for group B. Any incidence of maternal mortality was not evident among the two study groups and statistically insignificant ADR like vomiting and maculopapular rash (p-value=0.324) was observed in both the study groups with the use of above-mentioned antimicrobial therapy. Conclusion: Prophylactic use of ceftriaxone plus metronidazole and combination of triple antimicrobial therapy of ampicillin, metronidazole, and gentamycin therapy at the usual standard dose were commonly used antimicrobials at the present set up and they are safe and equally effective in decreasing considerably the incidence of post caesarean maternal infection thereby reducing their morbidity and mortality.

Accurate preoperative localization is crucial for successful minimally invasive parathyroidectomy in primary hyperparathyroidism (PHPT). Preoperative localization can be challenging in patients with recurrent and/or multigland disease (MGD). This has led clinicians to investigate multiple imaging techniques, most of which are associated with radiation exposure. Magnetic resonance imaging (MRI) offers ionizing radiation-free and accurate imaging, making it an attractive alternative imaging modality. The objective of this systematic review is to provide an overview of the diagnostic performance of MRI in the localization of PHPT. PubMed and Embase libraries were searched from 1 January 2000 to 31 March 2023. Studies were included that investigated MRI techniques for the localization of PHPT. The exclusion criteria were (1) secondary/tertiary hyperparathyroidism, (2) studies that provided no diagnostic performance values, (3) studies published before 2000, and (4) studies using 0.5 Tesla MRI scanners. Twenty-four articles were included in the systematic review, with a total of 1127 patients with PHPT. In 14 studies investigating conventional MRI for PHPT localization, sensitivities varied between 39.1% and 94.3%. When employing more advanced MRI protocols like 4D MRI for PHPT localization in 11 studies, sensitivities ranged from 55.6% to 100%. The combination of MR imaging with functional techniques such as 18F-FCH-PET/MRI yielded the highest diagnostic accuracy, with sensitivities ranging from 84.2% to 100% in five studies. Despite the limitations of the available evidence, the results of this review indicate that the combination of MR imaging with functional imaging techniques such as 18F-FCH-PET/MRI yielded the highest diagnostic accuracy. Further research on emerging MR imaging modalities, such as 4D MRI and PET/MRI, is warranted, as MRI exposes patients to minimal or no ionizing radiation compared to other imaging modalities.

Head and neck squamous cell carcinoma (HNSCC) has a large global burden of disease and poor survival outcomes. Recent targeted therapies and immunotherapies have been explored in HNSCC, but there has been limited translation to clinical practice outside of recurrent or metastatic cases. Window of opportunity settings, where novel agents are administered between cancer diagnosis and planned definitive therapy, have begun to be employed in HNSCC. Tumor tissue biopsies are obtained at diagnosis and after the investigation treatment, along with other biospecimens and radiographic exams. Thus, this study design can characterize the safety profiles, pharmacodynamics, and initial tumor responses to novel therapies in a treatment-naïve subject. Early window studies have also identified potential biomarkers to predict sensitivity or resistance to treatments. However, these early investigations have revealed multiple challenges associated with this trial design. In this review, we discuss recent window of opportunity trials in HNSCC and how they inform design considerations for future studies.

Abstract Background Anxiety is a behavioral expression of tension and unpleasant emotion that arises from multifactorial dimensions that might increase the mortality of patients during anesthesia and surgery. This study aimed to verify the prevalence and associated factors of preoperative anxiety among women undergoing elective cesarean delivery. Method A cross-sectional study design was conducted on a total of 392 patients who underwent elective cesarean delivery in Debre Tabor Comprehensive Specialized Hospital, in North Central Ethiopia from October 15, 2020, to September 15, 2021. Data was collected using a validated Amsterdam questionnaire, after translating to the local language (Amharic). Descriptive statistics were expressed in percentages and presented in tables. Bivariable and multivariable logistic analyses were done to identify factors associated with preoperative anxiety. The statistical significance level was set at P

Abstract Background Rehabilitation strategies after abdominal surgery enhance recovery and improve outcome. A cornerstone of rehabilitation is respiratory physiotherapy with inspiratory muscle training to enhance pulmonary function. Pre-habilitation is the process of enhancing functional capacity before surgery in order to compensate for the stress of surgery and postoperative recovery. There is growing interest in deploying pre-habilitation interventions prior to surgery. The aim of this study is to assess the impact of preoperative inspiratory muscle training on postoperative overall morbidity. The question is, whether inspiratory muscle training prior to elective abdominal surgery reduces the number of postoperative complications and their severity grade. Methods We describe a prospective randomized-controlled single-centre trial in a tertiary referral centre. The primary outcome is the Comprehensive Complication Index (CCI) at 90 days after surgery. The CCI expresses morbidity on a continuous numeric scale from 0 (no complication) to 100 (death) by weighing all postoperative complications according to the Clavien-Dindo classification for their respective severity. In the intervention group, patients will be instructed by physiotherapists to perform inspiratory muscle training containing of 30 breaths twice a day for at least 2 weeks before surgery using Power®Breathe KHP2. Depending on the surgical schedule, training can be extended up to 6 weeks. In the control group, no preoperative inspiratory muscle training will be performed. After the operation, both groups receive the same physiotherapeutic support. Discussion Existing data about preoperative inspiratory muscle training on postoperative complications are ambiguous and study protocols are often lacking a clear design and a clearly defined endpoint. Most studies consist of multi-stage concepts, comprehensively supervised and long-term interventions, whose implementation in clinical practice is hardly possible. There is a clear need for randomized-controlled studies with a simple protocol that can be easily transferred into clinical practice. This study examines the effortless adjustment of the common respiratory physiotherapy from currently postoperative to preoperative. The external measurement by the device eliminates the diary listing of patients’ performances and allows the exercise adherence and thus the effect to be objectively recorded. Trial registration ClinicalTrials.gov NCT04558151 . Registered on September 15, 2020.

IntroductionNeoadjuvant stereotactic radiosurgery (NaSRS) of brain metastases has gained importance, but it is not routinely performed. While awaiting the results of prospective studies, we aimed to analyze the changes in the volume of brain metastases irradiated pre- and postoperatively and the resulting dosimetric effects on normal brain tissue (NBT).MethodsWe identified patients treated with SRS at our institution to compare hypothetical preoperative gross tumor and planning target volumes (pre-GTV and pre-PTV) with original postoperative resection cavity volumes (post-GTV and post-PTV) as well as with a standardized-hypothetical PTV with 2.0 mm margin. We used Pearson correlation to assess the association between the GTV and PTV changes with the pre-GTV. A multiple linear regression analysis was established to predict the GTV change. Hypothetical planning for the selected cases was created to assess the volume effect on the NBT exposure. We performed a literature review on NaSRS and searched for ongoing prospective trials.ResultsWe included 30 patients in the analysis. The pre-/post-GTV and pre-/post-PTV did not differ significantly. We observed a negative correlation between pre-GTV and GTV-change, which was also a predictor of volume change in the regression analysis, in terms of a larger volume change for a smaller pre-GTV. In total, 62.5% of cases with an enlargement greater than 5.0 cm3 were smaller tumors (pre-GTV < 15.0 cm3), whereas larger tumors greater than 25.0 cm3 showed only a decrease in post-GTV. Hypothetical planning for the selected cases to evaluate the volume effect resulted in a median NBT exposure of only 67.6% (range: 33.2–84.5%) relative to the dose received by the NBT in the postoperative SRS setting. Nine published studies and twenty ongoing studies are listed as an overview.ConclusionPatients with smaller brain metastases may have a higher risk of volume increase when irradiated postoperatively. Target volume delineation is of great importance because the PTV directly affects the exposure of NBT, but it is a challenge when contouring resection cavities. Further studies should identify patients at risk of relevant volume increase to be preferably treated with NaSRS in routine practice. Ongoing clinical trials will evaluate additional benefits of NaSRS.

Background: Glioblastoma is a high-grade aggressive neoplasm whose outcomes have not changed in decades. In the current treatment pathway, tumour growth continues and remains untreated for several weeks post-diagnosis. Intensified upfront therapy could target otherwise untreated tumour cells and improve the treatment outcome. POBIG will evaluate the safety and feasibility of single-fraction preoperative radiotherapy for newly diagnosed glioblastoma, assessed by the maximum tolerated dose (MTD) and maximum tolerated irradiation volume (MTIV). Methods: POBIG is an open-label, dual-centre phase I dose and volume escalation trial that has received ethical approval. Patients with a new radiological diagnosis of glioblastoma will be screened for eligibility. This is deemed sufficient due to the high accuracy of imaging and to avoid treatment delay. Eligible patients will receive a single fraction of preoperative radiotherapy ranging from 6 to 14 Gy followed by their standard of care treatment comprising maximal safe resection and postoperative chemoradiotherapy (60 Gy/30 fr) with concurrent and adjuvant temozolomide). Preoperative radiotherapy will be directed to the part of the tumour that is highest risk for remaining as postoperative residual disease (hot spot). Part of the tumour will remain unirradiated (cold spot) and sampled separately for diagnostic purposes. Dose/volume escalation will be guided by a Continual Reassessment Method (CRM) model. Translational opportunities will be afforded through comparison of irradiated and unirradiated primary glioblastoma tissue. Discussion: POBIG will help establish the role of radiotherapy in preoperative modalities for glioblastoma. Trial registration: NCT03582514 (clinicaltrials.gov).

Background: Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CCA) is a rare form of primary liver malignancy. Microvascular invasion (MVI) indicates poor postsurgical prognosis in cHCC-CCA. The objective of this study was to investigate preoperative predictors of MVI in hepatitis B virus (HBV) -related cHCC-CCA patients. Methods: A total of 69 HBV-infected patients with pathologically confirmed cHCC-CCA who underwent hepatectomy were included. Univariate and multivariate analyses were conducted to determine independent risk factors that were then incorporated into the predictive model associated with MVI. Receiver operating characteristic analysis was used to assess the predictive performance of the new model. Results: For the multivariate analysis, γ-glutamyl transpeptidase (OR, 3.69; p = 0.034), multiple nodules (OR, 4.41; p = 0.042) and peritumoral enhancement (OR, 6.16; p = 0.004) were independently associated with MVI. Active replication of HBV indicated by positive HBeAg showed no differences between MVI-positive and MVI-negative patients. The prediction score using the independent predictors achieved an area under the curve of 0.813 (95% CI 0.717–0.908). A significantly lower recurrence-free survival was observed in the high-risk group with a score of ≥1 (p < 0.001). Conclusion: γ-glutamyl transpeptidase, peritumoral enhancement and multiple nodules were independent preoperative predictors of MVI in HBV-related cHCC-CCA patients. The established prediction score demonstrated satisfactory performance in predicting MVI pre-operatively and may facilitate prognostic stratification. [ABSTRACT FROM AUTHOR]

Background: Home-based and supervised prehabilitation programmes are shown to have a positive impact on outcomes in patients with oesophago-gastric (OG) cancer. The primary aim of this study was to establish the feasibility of delivering a digital prehabilitation service. Methods: Patients undergoing treatment for OG cancer with curative intent were recruited into the study. During the COVID-19 pandemic, patients were offered a digital prehabilitation service. Following the lifting of COVID-19 restrictions, patients were also offered both a hybrid clinic-based in-person service and a digital service. Implementation and clinical metrics from the two prehabilitation models were compared. Results: 31 of 41 patients accepted the digital service (75%). Of the people who started the digital programme, 3 dropped out (10%). Compliance with the weekly touchpoints was 86%, and the median length of programme was 12 weeks. Twenty-six patients enrolled in the in-person service. Two patients dropped out (10%). Average compliance to weekly touchpoints was 71%, and the median length of programme was 10 weeks. In the digital group, sit to stand (STS) increased from 14.5 (IQR 10.5–15.5) to 16 (IQR 16–22); p = 0.02. Median heart rate recovery (HRR) increased from 10.5 (IQR 7.5–14) to 15.5 (IQR 11–20) bpm; p = 0.24. There was a significant drop in distress (median 3 (IQR 0–5) to 1 (IQR 0–2); p = 0.04) and a small drop in anxiety (median 3 (0–5) to 2 (0–3); p = 0.22). There was no difference in the postoperative complication rate and length of hospital stay between the two groups. Discussion: This study has shown that digital prehabilitation can be delivered effectively to patients with OG cancer, with high engagement and retention rates. We observed improvements in some physical and psychological parameters with the digital service, with comparable clinical outcomes to the in-person service. [ABSTRACT FROM AUTHOR]

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1–2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9–3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19–1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02–1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0–1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications. [ABSTRACT FROM AUTHOR]

Background: Preoperative anemia is common and associated with adverse postoperative outcomes. Assessment of hemoglobin concentrations may facilitate optimization prior to surgery. However, phlebotomy‐based hemoglobin measurement may contribute to patient discomfort and iatrogenic blood loss, which makes non‐invasive hemoglobin estimation attractive in this setting. Study Design and Methods: This is a prospective study of adult patients presenting for preoperative evaluation before elective surgery at a tertiary care medical center. The Masimo Pronto Pulse CO‐Oximeter was utilized to estimate blood hemoglobin concentrations (SpHb), which were then compared with hemoglobin concentrations obtained via complete blood count. Receiver operating curves were used to identify SpHb values maximizing specificity for anemia detection while meeting a minimum sensitivity of 80%. Results: A total of 122 patients were recruited with a median (interquartile range) age of 66 (58, 72) years. SpHb measurements were obtained in 112 patients (92%). SpHb generally overestimated hemoglobin with a mean (± 1.96 × standard deviation) difference of 0.8 (−2.2, 3.9) g/dL. Preoperative anemia, defined by hemoglobin <12.0 g/dL in accordance with institutional protocol, was present in 22 patients (20%). The optimal SpHb cut‐point to identify anemia was 13.5 g/dL: sensitivity 86%, specificity 81%, negative predictive value 96%, and positive predictive value 53%. Utilizing this cut‐point, 60% (73/122) of patients could have avoided phlebotomy‐based hemoglobin assessment, while an anemia diagnosis would have been missed in <3% (3/122). Conclusion: The use of SpHb devices for anemia screening in surgical patients is feasible with the potential to reliably rule‐out anemia despite limited accuracy. [ABSTRACT FROM AUTHOR]

The Centre for Perioperative Care (CPOC) has published in September 2022 guidance addressing perioperative anaemia. This editorial addresses the definition of anaemia for women and management of borderline anaemia in women. We also address implications of the CPOC guidance for anaesthetists and the future direction of anaemia research and management. [ABSTRACT FROM AUTHOR]

Prehabilitation employs exercise, nutrition, and psychological interventions to optimize physiological status in preparation for surgery. First, we described the extent to which material deprivation index score (MDIS) influenced prehabilitation participation. Second, we evaluated the extent to which prehabilitation influenced recovery as compared to control. Pooled patient records from prospective multimodal prehabilitation studies in oncologic surgery were retrospectively examined. Patient postal codes were linked to their MDIS, a validated area-level socioeconomic status (SES) metric, as quintiles 1-5 (1 = highest SES). Functional capacity was evaluated with the 6-min walking test (6MWT) at baseline, before, and 8 weeks post-surgery. Influence of prehabilitation on length of hospital stay (LOS) was explored using generalized linear models with a negative binomial distribution adjusted for age, sex, surgical population, and MDIS. Recruitment records were available from 2014 onwards, yielding 1013 eligible patients for prehabilitation participation with MDIS data. Fewer patients with a low SES enrolled (Q1:62% vs. Q5:47%; P = 0.01) and remained in prehabilitation studies (Q1: 59% vs. Q5: 45%; P = 0.07). Prehabilitation study records were available from 2008 onward, yielding 886 enrolled patients with MDIS data (n = 510 prehabilitation, n = 376 control). Preoperative 6MWT similarly improved by > 20 m in response to prehabilitation across SES strata (P < 0.05). Postoperative 6MWT could not be evaluated due to substantial missing data. Prehabilitation had a significant protective influence on LOS, as compared to control, in unadjusted and adjusted models [adjusted IRR:0.77 (95% CI:0.68 to 0.87; P < 0.001]. Findings suggest that prehabilitation is effective across all SES; however, participation across SES quintiles was not equal. Barriers to participation must be identified and addressed. Once these barriers are addressed, prehabilitation may reduce surgical disparities among SES. [ABSTRACT FROM AUTHOR]

Background: Loss of knee extension (LOE) after anterior cruciate ligament reconstruction (ACLR) is associated with limited knee joint function and increased risk for knee osteoarthritis. Hypothesis: Preoperative LOE will affect postoperative LOE for up to 12 months after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: Included were patients who underwent anatomic ACLR between June 2014 and December 2018. In all patients, the postoperative rehabilitation protocol was the same. A heel height difference (HHD) ≥2 cm between the affected and the contralateral leg was used as a measure of LOE. Based on preoperative HHD, patients were divided into LOE and no-LOE groups. The HHD was reevaluated at 1, 3, 4, 6, 9, and 12 months postoperatively. Proportional hazards analysis was used, with the dependent variable being whether a postoperative HHD <2 cm was achieved; the independent variables being the presence or absence of preoperative LOE; and the adjusted variables being age, sex, time to surgery, and presence of meniscal sutures. Results: A total of 389 patients (208 female, 181 male; median age, 21.0 years) were included in the study. There were 55 patients in the LOE group and 334 patients in the no-LOE group. The incidence of LOE at 12 months after ACLR was 13.8% in the no-LOE group and 38.2% in the LOE group (P <.001), with an absolute risk difference of 24.4%. The hazard ratio for achieving postoperative HHD <2 cm was 2.79 for the LOE group versus the no-LOE group (P <.001). Conclusion: Patients with preoperative LOE were nearly 3 times more likely than those without LOE to have LOE at 12 months after ACLR. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the pathological complete response (pCR) rate of locally advanced rectal cancer (LARC) after adaptive high-dose neoadjuvant chemoradiation (CRT) based on 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG-PET/CT). Methods: The primary endpoint was the pCR rate. Secondary endpoints were the predictive value of 18 F-FDG-PET/CT on pathological response and acute and late toxicity. All patients performed 18 F-FDG-PET/CT at baseline (PET0) and after 2 weeks during CRT (PET1). The metabolic PET parameters were calculated both at the PET0 and PET1. The total CRT dose was 45 Gy to the pelvic lymph nodes and 50 Gy to the primary tumor, corresponding mesorectum, and to metastatic lymph nodes. Furthermore, a sequential boost was delivered to a biological target volume defined by PET1 with an additional dose of 5 Gy in 2 fractions. Capecitabine (825 mg/m2 twice daily orally) was prescribed for the entire treatment duration. Results: Eighteen patients (13 males, 5 females; median age 55 years [range, 41–77 years]) were enrolled in the trial. Patients underwent surgical resection at 8–9 weeks after the end of neoadjuvant CRT. No patient showed grade > 1 acute radiation-induced toxicity. Seven patients (38.8%) had TRG = 0 (complete regression), 5 (27.0%) showed TRG = 2, and 6 (33.0%) had TRG = 3. Based on the TRG results, patients were classified in two groups: TRG = 0 (pCR) and TRG = 1, 2, 3 (non pCR). Accepting p < 0.05 as the level of significance, at the Kruskal–Wallis test, the medians of baseline-MTV, interim-SUVmax, interim-SUVmean, interim-MTV, interim-TLG, and the MTV reduction were significantly different between the two groups. 18 F-FDG-PET/CT was able to predict the pCR in 77.8% of cases through compared evaluation of both baseline PET/CT and interim PET/CT. Conclusions: Our results showed that a dose escalation on a reduced target in the final phase of CRT is well tolerated and able to provide a high pCR rate. [ABSTRACT FROM AUTHOR]

Background: Preoperative anemia is a common complication in knee osteoarthritis (KOA) patients. However, the association between anemia and preoperative deep vein thrombosis (DVT) in osteoarthritis patients remains unknown. The aim of this study was to investigate such association. Methods: In this retrospective study, we included 1005 KOA patients undergoing total knee arthroplasty (TKA) in our hospital. According to preoperative hemoglobin levels, the patients were divided into anemia group and non-anemia group. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. A logistic model was established through propensity score matching (PSM), with anemia before TKA as the dependent variable, DVT-related variable as the covariate, and 0.03 as the Caliper value. The anemia group and non-anemia group were matched at a 1:1 ratio and 310 successfully matched. After matching, logistic regression analysis was used to evaluate the correlation between preoperative anemia and DVT in KOA patients. Results: In this study, 342 cases (33.6%) had preoperative anemia and 73 cases (7.2%) had DVT before TKA. After matching, 46 DVT cases (7.42%) were found. By using binary logistic regression after PSM, we found that the risk for preoperative DVT formation in TKA patients with preoperative anemia increased by 1.97 times [95% (CI 1.05–3.69)], P = 0.035. Conclusion: Preoperative anemia is considered as an independent risk factor for the formation of preoperative DVT in KOA patients. Trial registration: ChiCRT2100054844. [ABSTRACT FROM AUTHOR]

Introduction: In the era of virtual care, self-reported tools are beneficial for preoperative assessments and facilitating postoperative planning. We have previously reported the use of the Edmonton Frailty Scale (EFS) as a valid preoperative assessment tool. Objective: We wished to validate the self-reported domains of the EFS (srEFS) by examining its association with loss of independence (LOI) and mortality. Methods: This is a post-hoc analysis of a single-institution observational study of patients 65 years of age or older undergoing multi-specialty surgical procedures and assessed with the EFS in the preoperative setting. Exploratory data analysis was used to determine the threshold for identifying frailty using the srEFS. Procedures were classified using the Operative Stress Score (OSS) scored 1 to 5 (lowest to highest). Hierarchical Condition Category (HCC) was utilized to risk-adjust. LOI was described as requiring more support at discharge and mortality was defined as death occurring up to 30 days following surgery. Receiver operating characteristic (ROC) curves were used to determine the ability of the srEFS to predict the outcomes of interest in relation to the EFS. Results: Five hundred thirty-five patients were included. Exploratory analysis confirmed best positive predictive value for srEFS was greater or equal to 5. Overall, 113 (21 percent) patients were considered high risk for frailty (HRF) and 179 (33 percent) patients had an OSS greater or equal to 5. LOI occurred in 7 percent (38 patients) and the mortality rate was 4 percent (21 patients). ROC analysis showed that the srEFS performed similar to the standard EFS with no difference in discriminatory thresholds for predicting LOI and mortality. Examination of the domains of the EFS not included in the srEFS demonstrated a lack of association between cognitive decline and the outcomes of interest. However, functional status assessed with either the Get up and Go (EFS only) or self-reported ADLs was independently associated with increased risk for LOI. Conclusion: This study shows that self-reported EFS may be an optional preoperative tool that can be used in the virtual setting to identify patients at HRF. Early identification of patients at risk for LOI and mortality provides an opportunity to implement targeted strategies to improve patient care. [ABSTRACT FROM AUTHOR]

Objectives: To explore the effects of preoperative high‐intensity interval training (HIIT) compared to usual care on tumour natural killer (NK)‐cell infiltration in men with localised prostate cancer (PCa), as NK‐cell infiltration has been proposed as one of the key mechanisms whereby exercise can modulate human tumours. Patients and Methods: A total of 30 patients with localised PCa undergoing radical prostatectomy (RP) were randomised (2:1) to either preoperative aerobic HIIT four‐times weekly (EX; n = 20) or usual care (CON; n = 10) from time of inclusion until scheduled surgery. Tumour NK‐cell infiltration was assessed by immunohistochemistry (CD56+) in diagnostic core needle biopsies and corresponding prostatic tissue from the RP. Changes in cardiorespiratory fitness, body composition, blood biochemistry, and health‐related quality of life were also evaluated. Results: The change in tumour NK‐cell infiltration did not differ between the EX and CON groups (between‐group difference: −0.09 cells/mm2, 95% confidence interval [CI] –1.85 to 1.66; P = 0.913) in the intention‐to‐treat analysis. The total number of exercise sessions varied considerably from four to 30 sessions. The per‐protocol analysis showed a significant increase in tumour NK‐cell infiltration of 1.60 cells/mm2 (95% CI 0.59 to 2.62; P = 0.004) in the EX group. Further, the total number of training sessions was positively correlated with the change in NK‐cell infiltration (r = 0.526, P = 0.021), peak oxygen uptake (r = 0.514, P = 0.035) and peak power output (r = 0.506, P = 0.038). Conclusion: Preoperative HIIT did not result in between‐group differences in tumour NK‐cell infiltration. Per‐protocol and exploratory analyses demonstrate an enhanced NK‐cell infiltration in PCa. Future studies are needed to test the capability of exercise to increase tumour immune cell infiltration. [ABSTRACT FROM AUTHOR]

To analyze the risk factors for preoperative deep vein thrombosis (DVT) in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA). In this retrospective study, a total of 584 knee OA patients undergoing TKA were enrolled. General information, medical records and preoperative laboratory examination results of the patients were collected. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. Univariate and multivariate logistic regression were used to identify independent risk factors for preoperative DVT in knee OA patients undergoing TKA. The incidence of DVT before TKA was 6.85% (40 cases). The increase of ESR (Erythrocyte Sedimentation Rate), platelet crit, IL-6 (Interleukin-6), and PCT (Procalcitonin) were associated with the development of DVT before TKA. Factors as coronary heart disease (CHD), diabetes mellitus (DM), Chronic Kidney Disease (CKD), NLR (ratio of neutrophils to lymphocytes), lower limb venous blood stasis, the time from onset to admission, RBC, PLT were identified by multivariate logistic regression to be the independent risk factors for preoperative DVT in knee OA patients undergoing TKA. DM, CKD, CHD, increased in ESR, IL-6 and PCT, blood stasis of the lower extremities, increased in PLT, platelet crit and the time from onset to admission, decreased in RBC, were high risk factors for preoperative DVT in knee OA patients undergoing TKA. [ABSTRACT FROM AUTHOR]

This was a retrospective study that evaluated a total of 280 patients who underwent surgery for complete removal of endometriosis to develop and validate the predictive model for stage IV endometriosis. The differences between stage I-III and stage IV endometriosis were performed by logistic regression. A model for the prediction of stage IV endometriosis was constructed, which was subsequently validated. The independent variables were visual analogue scale (VAS)≥4 [3.855, 95% confidence interval (CI): 1.675–8.871, p = 0.002], painful nodularity on uterosacral ligaments (13.954, 95% CI: 1.658–117.423, p = 0.015), and bilateral endometriosis (5.933, 95% CI: 1.931–18.225, p = 0.002). The AUC of the model was 0.777, with a sensitivity of 71.9% and specificity of 76.3% for stage IV endometriosis. Therefore, a complete collection of patient information prior to surgery, asking about pain and VAS scores, careful completion of pelvic examinations, and application of imaging techniques are conducive to better diagnosis and prediction of advanced endometriosis. What is already known on this subject? Endometriosis, a chronic disease causing pain and infertility, is characterised by endometrial-like tissue outside the uterine cavity, which is often treated via surgery at present. Considering the risks of surgery, it is necessary to identify patients with stage IV endometriosis through non-invasive predictive models for adequate preparation for surgery. However, there is no reliable non-invasive predictive model now, despite utilisation of patient medical history, symptoms especially pain-related ones, pelvic examinations, laboratory examinations, and images in the preoperative diagnosis of endometriosis in the clinic. What do the results of this study add? A model developed based on three simple, accessible and non-invasive indicators displays good performance in predicting stage IV endometriosis. What are the implications of these findings for clinical practice and/or further research? It is conducive to diagnosing and predicting advanced endometriosis before surgery, so as to reduce the difficulty and improve the safety of surgery. [ABSTRACT FROM AUTHOR]

Objective: To study the effects of music on anxiety in patients undergoing hair transplantation. Materials and Methods: This randomized controlled trial enrolled patients undergoing hair transplantation. The patients were randomized into a music group, who listened to music for 15 minutes during the preoperative period, and a control group, who were not exposed to music. Two scales were used to measure anxiety. One was the State- Trait Anxiety Inventory (STAI), comprised of a state anxiety scale (STAI-S) and trait anxiety scale (STAI-T). The other was the Visual Analog Scale for Anxiety (VASA). Demographic and physical parameters (blood pressure, heart rate, and respiratory rate) were recorded. Results: The 26 patients had a mean age of 40.8 ± 10.4 years. Twenty-three (88.5%) were men. The 2 groups had no significant differences in their STAI-S or VASA scores, or physical parameters before and after intervention. The STAI-S score of the control group significantly increased with time (P = 0.027). Additionally, a significant decrease in the VASA score was observed after the intervention for the music group (P = 0.039). No adverse events were noted. Conclusion: Listening to music is an easy, effective, and safe method of reducing preoperative anxiety in patients undergoing hair transplantation. The method should be employed during the preoperative period for patients undergoing hair transplantation. It may also be considered for use in similar procedures. [ABSTRACT FROM AUTHOR]

Background: Postoperative stereotactic radiosurgery (SRS) is a standard management option for patients with resected brain metastases. Preoperative SRS may have certain advantages compared to postoperative SRS, including less uncertainty in delineation of the intact tumor compared to the postoperative resection cavity, reduced rate of leptomeningeal dissemination postoperatively, and a lower risk of radiation necrosis. The recently published ASCO-SNO-ASTRO consensus statement provides no recommendation for the preferred sequencing of radiotherapy and surgery for patients receiving both treatments for their brain metastases. Methods: This multicenter, randomized controlled trial aims to recruit 88 patients with resectable brain metastases over an estimated three-year period. Patients with ten or fewer brain metastases with at least one resectable, fulfilling inclusion criteria will be randomized to postoperative SRS (standard arm) or preoperative SRS (investigational arm) in a 1:1 ratio. Randomization will be stratified by age (< 60 versus ≥60 years), histology (melanoma/renal cell carcinoma/sarcoma versus other), and number of metastases (one versus 2–10). In the standard arm, postoperative SRS will be delivered within 3 weeks of surgery, and all unresected metastases will receive primary SRS. In the investigational arm, enrolled patients will receive SRS of all brain metastases followed by surgery of resectable metastases within one week of SRS. In either arm, single fraction or hypofractionated SRS in three or five fractions is permitted. The primary endpoint is to assess local control at 12 months in both arms. Secondary endpoints include local control at other time points, regional/distant brain recurrence rates, leptomeningeal recurrence rates, overall survival, neurocognitive outcomes, and adverse radiation events including radiation necrosis rates in both arms. Discussion: This trial addresses the unanswered question of the optimal sequencing of surgery and SRS in the management of patients with resectable brain metastases. No randomized data comparing preoperative and postoperative SRS for patients with brain metastases has been published to date. Trial registration: , NCT04474925; registered on July 17, 2020. Protocol version 1.0 (January 31, 2020). Sponsor: Alberta Health Services, Edmonton, Canada (Samir Patel, MD). [ABSTRACT FROM AUTHOR]

Purpose: The safety of an MRI simulation-guided boost after short-course preoperative radiotherapy (SCPRT) for unresectable rectal cancer is assessed with a planned interim analysis. Methods and materials: Patients diagnosed with clinical stage T3-4 or regional lymph node-positive disease with positive mesorectal fascia or T4b disease evaluated by pelvic MRI were randomly assigned to the SCPRT-boost group (25 Gy in 5 fractions plus 4 Gy delivered to the gross tumor volume, followed by four cycles of chemotherapy) or preoperative chemoradiotherapy group (50 Gy in 25 fractions with concurrent chemotherapy). Then, patients received total mesorectal excision surgery after preoperative treatment. The primary endpoint was the R0 resection rate. The interim analysis was performed when 42 patients completed their assigned treatments. Results: From October 2018 to November 2019, a total of 43 patients were enrolled, and 42 patients were included in the interim analysis. During preoperative therapy, grade 3 or above toxicities were observed in 10/21 (47.6%) patients in the experimental group, and 4/21 (19.0%) patients in the control group. A total of 17 (81.0%) and 13 (61.9%) patients in the experimental group and control group underwent surgery, respectively. Overall, 65.1% of the patients achieved R0 resection in the intention-to-treat analysis. Surgery-related adverse complications were observed in 2 patients (11.8%) in the experimental group and 1 patient (7.7%) in the control group. Conclusion: Our results show that the toxicity of an MRI simulation-guided boost after SCPRT for unresectable rectal cancer is acceptable. Thus, this clinical trial will be continued as planned. [ABSTRACT FROM AUTHOR]