Surgical Management Of Patients Research Articles

A Retrospective Study of Degenerative Cervical Myelopathy and the Surgical Management Within Northern Ireland.

Degenerative cervical myelopathy (DCM) is a condition of growing concern due to its increasing incidence among the ageing population. It involves age-associated pathological changes of the cervical spine that can result in spinal cord compression. This can lead to deficits in motor and sensory function of the upper and lower limbs, issues with balance and dexterity, as well as bladder and bowel disturbance. Patients can be categorised as having mild, moderate, or severe degenerative cervical myelopathy depending on their modified Japanese Orthopaedic Association (mJOA) score. This condition is generally managed surgically; however, patients with mild degenerative cervical myelopathy may be offered or opt for non-surgical treatment initially. The main aim of this study is to evaluate the surgical management of patients with DCM and to ascertain the degree of mJOA improvement from pre-surgery and one-year post-surgery follow-up. The second aim of the study is to explore the demographics within Northern Ireland who are diagnosed with DCM and who undergo surgery. This information could allow for better planning of services in the future for this patient cohort. This is a retrospective review of the surgical management of degenerative cervical myelopathy within the Regional Spinal Orthopaedic Unit in Northern Ireland over three years with one-year follow-up. The data was retrospectively collected from the Fracture Outcome Research Database. A total of 102 patients (10:7, male:female) with DCM were retrospectively evaluated. Exclusion criteria included all patients diagnosed with spinal tumour, fracture, central cord syndrome, and dislocation. Two patients were removed due to incorrect coding of DCM diagnosis and were not included. Key variables assessed were gender, age, symptoms, type of surgery, complications, and MRC score and mJOA score pre-surgery, 48 hours, six months, and one year post surgery. The choice of surgery was guided by the maximal angle of compression, the number of vertebral levels involved, patient comorbidities, and anesthetic risk. The sample consisted of 60 men (58.82%) and 42 women (41.17%) with an average age of 57.17 ± 12.13 years ranging from 27 to 83 years old. Statistical analysis was conducted to explore the effect of time before and after surgery up to one year on the mJOA score. There was a significant difference in mJOA score pre-surgery and at six months and one year post surgery (R = 0.579053, p <0.001). Of the patients,61.8% with a length of stay greater than three days and 71.4% of patients with a length of stay greater than seven days had a posterior approach surgery. A multiple linear regression analysis revealed that the mJOA score pre-surgery and the presence of complications significantly predicted the length of stay post-surgery (β -1.044, p = .011 and β -5.791, p = .028). The first key finding of this study is that the mJOA score tends to improve after surgery for the majority of patients, particularly at six months, which is consistent with the literature. The second key finding is that anterior approach surgery is associated with a lower rate of complications and shorter post-surgery length of stay in hospital compared to posterior approach surgery. The third key finding is that the pre-surgery mJOA score and the presence of complications post surgery significantly predict the post-surgery length of stay.

Stereotactic ablative radiotherapy for primary renal cell carcinoma

Stereotactic ablative radiotherapy (SAbR) is an emerging non-invasive definitive treatment option for primary renal cell carcinoma (RCC), particularly when surgery is not ideal. Employing ablative doses, SAbR delivered in one to five fractions to the primary tumor has been shown to achieve high local control rates with favorable toxicity profile in multiple retrospective and prospective series, and has dispelled previous notions of RCC radio-resistance. Moreover, emerging evidence suggests possible immunomodulatory effects, leading to clinical investigations of SAbR in combination with systemic and surgical management in patients with metastatic disease. In this review, we summarize key evidence supporting SAbR delivered to the primary tumor including preclinical rationale, dose escalation studies, recent prospective trials, and outcomes from ongoing multi-institutional registries. We also discuss areas of active clinical investigation including the use of primary SAbR in combination with systemic therapies in patients with metastatic disease. The accumulated body of evidence supports SAbR as promising indication being increasingly incorporated into the multi-disciplinary management of primary RCC.

Randomized trial of shunt infection rates comparing intraoperative Vancomycin versus Gentamicin in ventriculoperitoneal shunt system preparation

BackgroundVentriculoperitoneal (VP) shunt is the mainstay of surgical management of patients with hydrocephalus. The insertion of ventriculoperitoneal shunt may be accompanied by many potentially life-threatening complications including shunt infection. Concerted efforts have been made to reduce shunt infection rates, including use of saline- antibiotic solutions containing antibiotics such as Gentamicin, mixture of Gentamicin and Vancomycin in shunt system preparation. We therefore set out to determine the infection rates following the use of intraoperative Gentamicin and Vancomycin in ventriculoperitoneal shunt system preparation and compare the infection rates. Therefore, a randomized single blind comparative study was carried out for a period of seventeen months, among 56 patients that presented to 2 tertiary health centers in Nigeria diagnosed of hydrocephalus. Patients were randomized into Vancomycin- and Gentamicin-shunt preparation groups. The outcome measure was postoperative shunt infection rates. Statistical analysis was performed using SPSS software (version) 21. Group comparisons were made using the Student's t-test for numerical variables, and chi-square test or fisher’s exact test for categorical variables. Statistical significance was inferred at p-value < 0.05.ResultFifty-six patients were included in the study. One patient was lost to follow-up in Vancomycin group. Another patient died in Gentamicin group of sudden death without the patient exhibiting symptoms of shunt infection leaving a total of 54 for analysis. All the patients included in the study were followed up for six months. Their mean ages were between 1688.5 ± 665.3 (days) for Vancomycin group and 10,222 ± 6635.8 (days) for Gentamicin group. There was male preponderance of 55.6% as against female of 44.4%. Majority of the hydrocephalus were of congenital cause accounting for 64.8%. There was one shunt infection in the Gentamicin group giving rise to an infection rate of 1.9% which was not statistically significant (P –value—0.313). The organism isolated was Pseudomonas species.ConclusionVentriculoperitoneal shunt infection rates can be reduced to the barest minimum if standard concentration of antibiotics is used to prepare the shunt hardware employing a standard surgical technique.

SURG-04. FAST DETECTION OF GLIOMA INFILTRATION USING LABEL-FREE OPTICAL MICROSCOPY AND DEEP NEURAL NETWORKS

Abstract INTRODUCTION Fast and accurate detection of tumor infiltration is a central challenge in the comprehensive management of diffuse glioma patients. Despite our best real-time tumor detection strategies, such as intraoperative MRI and fluorescence-guided surgery, dense and safely resectable tumor infiltration remains at the surgical margin in over 85% of diffuse glioma patients. Patterns of treatment failure demonstrate that glioma recurrence occurs at the surgical margin in the majority of patients due to residual tumor burden. Objective Here, we present FastGlioma, an artificial intelligence (AI)-based intraoperative diagnostic system for fast (&amp;lt; 10 seconds) detection of diffuse glioma infiltration at microscopic resolution without the need for tumor-specific markers. Method FastGlioma is trained using large-scale, self-supervised visual feature learning on stimulated Raman histology (SRH), a rapid, label-free, optical microscopy technique, and a GPT-style whole slide SRH tumor infiltration scoring method. We pushed the performance limits of FastGlioma by investigating the trade-off between imaging speed versus accuracy for microscopic tumor detection. RESULTS In a large prospective external testing cohort of diffuse glioma patients (180 patients, 935 surgical margin specimens) who underwent intraoperative SRH imaging, we demonstrate that FastGlioma was able to detect and quantify microscopic tumor infiltration with an average AUROC of 92.1 +/- 0.0%, performing on par with three expert neuropathologists on the same task. FastGlioma is over 10X faster than previous SRH-based methods and 100X faster than conventional H&amp;E histology. Finally, we demonstrate that FastGlioma was &amp;gt; 20% more accurate at detecting dense tumor infiltration when compared to radiologic features or 5-aminolevulinic fluorescence (98.0% versus 77.8% accuracy) for both IDH-mutant diffuse gliomas and IDH-wildtype glioblastomas. CONCLUSION Our results demonstrate how intraoperative optical imaging and deep neural networks can achieve fast and accurate tumor detection, unlocking the role of AI in improving the surgical management of brain tumor patients.

Abstract 15187: Risk Factors for Type B Dissection in Marfan Syndrome: The Cornell Aortic Aneurysm Registry

Introduction/Background: With improvements in the medical and surgical management of patients with Marfan syndrome (MFS), type A dissections are decreasing. As a corollary, most MFS dissections are now type B, for which risk factors remain largely uncertain. Research Questions/Hypothesis: In this prospective and retrospective observational study, we explore determinants of type B dissection risk in a large single-center MFS registry through analysis of systematic clinical and imaging data over four decades. Goals/Aim: Determinants of type B dissection risk in MFS will inform appropriate prognostication, management, and treatment of this patient population. Methods/Approach: Demographic and anthropometric features, cardiovascular disease, and surgical history were compared in MFS patients with and without type B dissection. Results/Data: Of 335 MFS patients, 56 (17%) experienced a type B dissection (versus type A in 9%). Patients with type B dissection were more likely to have undergone elective aortic root replacement (ARR; 75 vs. 46%, p&lt;0.001). 55% of patients had type B dissection a mean of 14.1 years after ARR, whereas 45% experienced type B dissection before ARR. Valve replacement was more common than valve-sparing repair in those with post-operative type B dissection (27% vs. 12%, p=0.02), although this difference was eliminated after adjusting for duration of post-operative follow up. 50 (89%) patients were aware of their MFS diagnosis prior to type B dissection. Among those with pre-dissection imaging, the descending aorta was normal or minimally dilated in 87%. In multivariable analyses, patients with type B dissection were more likely to have undergone ARR, mitral valve surgery, had a type II dissection, and to have lived longer. Conclusions: In our contemporary cohort, type B dissections are more common than type A. The associations of type B dissection with ARR, mitral surgery, and type II dissection suggest a more severe phenotype in the setting of prolonged life expectancy.

Mise au point de la Société française du glaucome sur la place des nouvelles techniques chirurgicales dans le glaucome

The surgical management of glaucoma has been enriched in recent years by the arrival of new surgical techniques as a group known as MIGS (minimally invasive glaucoma surgery). The objective of these new techniques is to reduce intraocular pressure (IOP) while limiting the risk of complications of conventional filtering surgery and allowing faster visual recovery. MIGS can be classified into three main categories depending on the route used to promote the outflow of aqueous humor: the trabecular route, the suprachoroidal route and the subconjunctival route. MIGS using the subconjunctival route are also called minimally invasive bleb surgery (MIBS). These new techniques do not replace conventional filtering surgery, which remains the gold standard technique, but now offer new alternatives for the surgical management of glaucoma patients in combination with cataract surgery or as stand-alone procedures.

Assessment of quality of life in patients with surgically treated maxillofacial fractures.

Background: The complex nature of maxillofacial injuries can affect the surgical treatment outcomes and general well-being of the patient. To evaluate the efficiency of the surgical treatment, assessment of the quality of life (QOL) of the patients is of vital importance. Due to the absence of an exclusive QOL assessment tool for maxillofacial fractures, we introduce the 'Twenty-point quality of life assessment in facial trauma patients in Indian population'. The aim of this study was to assess and evaluate the QOL following surgical management of maxillofacial trauma patients based on the severity of the injury. Methods: The study consisted of 182 subjects divided into two groups of 91 each (Group A: severe facial injury and Group B: mild to moderate facial injury). The Facial Injury Severity Scale (FISS) was used to determine the severity of facial fractures and injuries. The twenty-point quality of life assessment tool includes Zone 1 (Psychosocial impact) and Zone 2 (Functional and aesthetic impact), with ten domains each to assess QOL. Results: In Zone 1, the mean scores for Group A and Group B were 38.6 and 39.26, respectively. In Zone 2, Group B (44.56) had higher mean scores compared to Group A (32.92) (p< 0.001). Group B (83.8) had higher mean scores compared to Group A (71.58) when the total of both Zone 1 and Zone 2 were taken into consideration (p<0,001). In Group A, 9 out of 91 patients had a total score of 81- 100 compared to 68 in the same range in Group B. Conclusions: Proper surgical management with adequate care to the hard and soft tissues can improve the QOL by reducing postoperative psychosocial and functional complications. Aesthetic outcomes play an important role in determining the QOL. Mild/ Moderate injuries show better QOL compared to severe maxillofacial injuries.

Approaches to the management of surgical patients with antibiotic-associated mild diarrhea

The paper highlights the issues of antibiotic-associated diarrhea (AAD) of mild severity in the treatment of surgical patients, its epidemiology, etiology, features of the clinical picture and approaches to therapy. The mild course of AAD includes diarrhea without signs of intoxication, leukocytosis and fever. Stool disorder in patients receiving antibiotics who are in a surgical hospital is an urgent medical problem, since this pathology prolongs the time of hospitalization, increases economic costs, reduces the quality of life and can even be the cause of the patient’s death. According to various authors, AAD develops in 40% of people receiving antibacterial therapy. A clinical example of the management of a patient with AAD and injury of the musculoskeletal system is considered in detail.The abolition of antibiotics is not a method of solving this problem, since the severity of the patient’s injuries requires further surgical treatment and prevention of purulent-septic complications. The key point in the treatment of mild AAD will be the appointment of probiotic drugs, which have an effect on the pathogenetic links of AAD. Probiotics are microorganisms that have been known since ancient times and are purposefully used for health improvement and longevity. One of the first probiotic drugs used before the era of the discovery of antibiotics can be considered Mechnikov curdled milk with unique medicinal properties. Prescribing probiotic therapy from the first day of taking antibiotics, without waiting for the results of laboratory examination, will significantly reduce the prevalence of clinical manifestations of both clostridial diarrhea and idiopathic AAD.

Diagnosis, Management and Outcomes in Children with Paget Schroetter Syndrome: A Retrospective Cohort Study

Introduction Venous thoracic outlet syndrome occurs secondary to the extrinsic compression and impingement of the subclavian vein as it passes through the thoracic outlet, eventually resulting in upper extremity effort thrombosis, or Paget-Schroetter syndrome (PSS). This rare condition typically affects the dominant arm of athletic young adults with a history of repeated overhead activities. At Boston Children's Hospital (BCH), a multidisciplinary team of hematologists, interventional radiologists, and vascular surgeons manage these patients according to a standardized protocol including anticoagulation, pharmaco-mechanical thrombolysis, venoplasty, and decompressive rib-resection surgery. Herein we report the clinical and radiological outcomes of a cohort of patients with PSS managed at BCH. Objective The principle objective of this retrospective cohort study was to review the diagnosis, pharmacological, interventional radiology and surgical management, complications, and long-term outcomes of sequential pediatric patients (≤21 years) treated for PSS at BCH over a 3.5-year period of time (January 1, 2020 to July 31, 2023). Methods This study was performed as a part of an ongoing quality improvement initiative and was deemed exempt by the Institutional Review Board. Eligible patients were defined as children (≤21 years) with PSS per criteria established by the Society for Vascular Surgery. Clinical and demographic data, including post-thrombotic syndrome (PTS) scores of eligible patients were abstracted from their medical records. PTS evaluation at BCH is typically performed 6-12 months after DVT diagnosis using both the modified Villalta and Manco-Johnson instruments. Major bleeding, and recurrent/progressive thromboses were defined per published guidelines by the International Society on Thrombosis and Haemostasis. Standard statistical methods were used - median (range) for continuous variables and frequency with 95% CI for categorical data. Results The study cohort consisted of 20 patients (9 female). PSS was confirmed based on dynamic imaging with provocative maneuvers for all patients. Median (range) age at DVT diagnosis was 17 (15-21) years. Thirteen patients were diagnosed at an outside hospital and referred to BCH for further management. Fourteen patients received upfront anticoagulation with low molecular weight heparin of whom 13 patients were transitioned to a DOAC. Six patients were started on DOACs upfront. Fifteen subjects (75%) received upfront endovascular intervention at diagnosis. Median interval between DVT diagnoses to endovascular intervention was 5 (1-118) days. All patients underwent decompressive rib-resection surgery. Median interval between DVT diagnosis and surgery was 12 (7-39) weeks. Three patients (15%) developed major bleeding and 3 (15%) patients developed recurrent/progressive thrombosis after surgery. Two of the 3 patients who developed major bleeding were anticoagulated with a DOAC pre-operatively, which had been held for 48 hours before surgery. All subjects had a planned post-operative venogram, 14 (70%) of whom underwent completion venoplasty. Anticoagulation was discontinued in 18/20 (90%) patients with a median duration of therapy of 19.5 (14-60) weeks. Four patients (20%) were noted to have an underlying thrombophilia (Factor 5 R506Q [2]; Factor 2 G20210A [1]; Protein S deficiency [1]). End-of-therapy imaging was obtained for all patients - 17 (85%) had complete thrombus resolution, while two (10%) had partial thrombus resolution. Seventeen (85%) patients have undergone evaluation for PTS, of whom 12 (71%) were noted to have mild PTS and 2 (12%) have moderate-severe PTS as defined by the modified Villata instrument. Discussion Greater than 90% of pediatric patients with PSS who were treated per our institutional multi-disciplinary protocol had complete or partial thrombus resolution. Additionally, only 12% of patients reported moderate to severe PTS on follow-up and were prescribed sequential compression sleeves. Lastly, DOACs appear to be safe and efficacious in this cohort, though based on our internal data, we now interrupt DOACs for 72 hours before decompressive surgery.

Empowering future surgeons: a workshop bridging the gap between graduation and the operating room.

Feedback from foundation trainees in Blackpool highlighted low levels of confidence with the prospect of surgical on-call shifts. Key areas of concern were assessing and managing the acute surgical patient, identifying which patients need an operation and having the technical skills to proficiently assist in theatre. This lack of confidence prevents trainees engaging in what should be an educational and rewarding rotation. The authors designed and facilitated a day of workshops, addressing these key educational needs. Bespoke to the trust's services, lectures were delivered by core surgical trainees on the assessment and management of acute surgical patients in general surgery, urology and trauma and orthopaedics. For the development of technical skills, an afternoon of surgical skills workshops covered suturing, knot tying, laparoscopic principles and theatre etiquette. Small groups of foundation trainees rotated through each workshop, delivered by surgical registrars (ST3+), to ensure high fidelity training. Pre- and post-course questionnaires assessed the efficacy of teaching. Out of a total of 72 foundation trainees, 55 attended the teaching day, of which 45 (81.8%) completed pre- and post-course surveys using a six-point modified Likert scale. Rates for satisfactory confidence levels while on-call improved from 66 to 100% of participants after the course. Suturing skills satisfaction rose from 37.5 to 100%, among other impact markers. All trainees that attended the course displayed a marked improvement. This course is now being incorporated into foundation teaching programmes at a regional level and has scope to be expanded nationally.

Access to surgical treatment for hepatopancreaticobiliary cancer in the Philippines

Hepatopancreaticobiliary cancers are among the most diagnosed cancers in the world. However, although high-income countries have the highest incidence rates, low- and middle-income countries have the highest mortality rates. In this article, we describe the geographic distribution of board-certified hepatopancreaticobiliary surgeons who provide surgical management for patients with these diseases in the Philippines. We draw attention to the geographic disparities in the distribution of these surgeons and the other factors that contribute to the lack of access. Lastly, we suggest ways forward.

Conventional and digital pleural drainage systems - advantages and disadvantages.

Pleural cavity drainage is a crucial component of the surgical management of patients with various chest diseases. Digital drainage systems are increasingly used in contemporary thoracic surgical procedure, which is likely a result of their effectiveness in achieving early postoperative ambulation, cutting down on hospital stays and lowering costs. The vast majority of thoracic surgeons worldwide prefer digital drainage systems to traditional ones. The advantages of the former, however, are disputed by some researchers.

Gender-Related Issues in the Management of Low-Back Pain: A Current Concepts Review.

Low back pain (LBP) is an emerging disease. This review aims to investigate the role of gender-related factors in the diagnosis, clinical, and surgical management of LBP. From January 2002 to March 2023, EMBASE, SCOPUS, OVID-MEDLINE, Google Scholar, PubMed, and Web of Science were searched to identify relevant papers for further analysis. Fifteen papers were included in this review. Sex- and gender-related differences were analyzed regarding the following points: (1) LBP epidemiology; (2) LBP physiopathology; (3) conservative management of LBP; (4) major vertebral surgery for LBP. The conservative treatment of LBP highlights that women claim services later in terms of poorer health status than men. In the postoperative phase, female patients show worse LBP, quality of life, and disability, but equal or greater interval change, compared with male patients complaining of lumbar degenerative disease. LBP epidemiology and clinical outcomes, following conservative and surgical management of patients complaining of back pain, might depend on both sex- and gender-related factors. It is mandatory to assess gender-related indicators in patients referred to LBP and address them to improve their clinical outcomes and quality of life.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary of Surgical Management of Osteoarthritis of the Knee.

The Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies for surgical management of osteoarthritis of the knee in skeletally mature patients. This guideline contains 16 recommendations and seven options to assist orthopaedic surgeons and all qualified physicians with the surgical management of patients with osteoarthritis of the knee based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Surgical management and post-operative functional outcomes of patients with a penile fracture-a single centre experience over 10years.

Penile fractures are uncommon urological emergencies which occur when there has been a breach in the tunica albuginea of the corpora cavernosum that may be unilateral and bilateral and can extend to involve the urethra. To assess the management and outcomes of penile fractures in a single institution in Ireland. A retrospective review of the emergency theatre logbooks was performed between 2011 and 2021 to identify patients who had undergone an exploration for a suspected penile fracture. Seventeen patients were initially identified on review of theatre logbooks as having an exploration for a suspected penile fracture. Two patients were excluded from the study due to a lack of clinical notes being available. A further 4 patients on chart review were found to not have a penile fracture at exploration. Eleven patients had a confirmed penile fracture intra-operatively, four of whom had an associated urethral injury. Nine (9/11) patients had preserved normal erections post-operatively documented on follow-up; two, however, reported erectile dysfunction requiring phosphodiesterase inhibitors. Our study supports urgent surgical exploration for penile fractures to ensure good functional outcomes. This is a retrospective review of theatre logbooks to identify patients with a suspected penile fracture. The results of our cohort show a good outcome of erectile function following surgical repair of a penile fracture (9/11; 82%). Four patients (4/11; 36%) had a urethral injury diagnosed intra-operatively, one of whom required a formal urethroplasty.

Assessing Changes in Colon Cancer Care during the COVID-19 Pandemic: A Four-Year Analysis at a Romanian University Hospital.

This retrospective study investigates the impact of the COVID-19 pandemic on the surgical management of patients with colon cancer in a tertiary University Hospital in Timisoara, Romania. Data from 867 patients who underwent surgical interventions for this condition between 26 February 2019 and 25 February 2023 were meticulously analyzed to evaluate substantial shifts in the management and outcomes of these patients in comparison to the pre-pandemic era. The results reveal a substantial decrease in elective surgical procedures (p < 0.001) and a significant increase in emergency interventions (p < 0.001). However, postoperative mortality did not show significant variations. Of concern is the diagnosis of patients at more advanced stages of colon cancer, with a significant increase in Stage IV cases in the second year of the pandemic (p = 0.045). Average hospitalization durations recorded a significant decrease (p < 0.001) during the pandemic, and an inverse correlation between patient age and surgery duration was reported (p = 0.01, r = -0.088). This analysis provides a comprehensive perspective on how the pandemic has influenced the management of colon cancer, highlighting significant implications for the management and outcomes of these patients.

FIGO statement: Fertility preservation.

Fertility preservation is a growing field in reproductive medicine that may raise ethical questions. Preservation of fertility must be discussed with the patient if gonadotoxic treatment is required, whether in the case of benign or malignant pathology, or in the management of transgender identity. As a result, surgery or chemotherapy that has fewer adverse impacts on fertility should be proposed if this does not alter the prognosis of the disease. If the risk of infertility persists, then fertility cryopreservation should be proposed for children and adults of reproductive age. Sperm, oocytes, and gonadal tissue can be cryopreserved for many years. FIGO wishes to emphasize the importance of fertility preservation in the medical and surgical management of patients, and the importance of a specialized, multidisciplinary approach.

THU223 Molecular Makeup Of Differentiated Thyroid Carcinoma In A Free-standing Children’s Hospital With A Predominantly Hispanic Population

Abstract Disclosure: A. Martinez: None. D. Baboun: None. N. Solano: None. R. Restrepo: None. C. Brathwaite: None. F. Alkhoury: None. A. Carrillo-Iregui: None. Background: Molecular testing has been incorporated into the clinical management of thyroid nodules in adults. The prevalence of oncogenic mutations and the role of molecular testing in the evaluation of thyroid nodules in children and adolescents have yet to be established. Objective: The purpose of this study is to identify the molecular makeup of thyroid nodules in patients diagnosed with differentiated thyroid carcinoma (DTC) at a free-standing children’s hospital with a predominantly Hispanic population. Methods: Upon Institutional Review Board approval, we reviewed the charts of all patients with a final diagnosis of DTC between 2012 and 2022. We analyzed demographics, histopathological diagnoses, and molecular oncogenic markers of pathology specimens when available. Statistical analysis was performed using Welch’s t-test and Fisher’s exact test. Results: Fifty-five patients between 8-20 years of age were diagnosed with DTC. Forty-nine (89.1%) patients identified as Hispanic, and 41 (74.6%) were females. Fifty-two (94.5%) patients had papillary thyroid carcinoma, and 3 (5.5%) had follicular thyroid carcinoma. Molecular testing was performed on 33 patients, of which 30 were positive for mutations and 3 undetected. BRAF V600E (43.3%) and RET/PTC (23.3%) were the most prevalent mutations detected. The average ages of patients with BRAF V600E and RET/PTC were 15.5 and 13.3 years, respectively with no statistical significance (p=.22). The average tumor sizes of patients with BRAF V600E and RET/PTC were 1.82 ± 0.95 cm and 2.5 ± 1.21 cm, respectively with no statistical significance (p=.12). Of the patients with BRAF V600E, 53.9% had lymph node involvement and none had metastasis. Of the patients with RET/PTC, 42.9% had lymph node involvement and 14.3% had metastasis. When comparing BRAFV600E and RET/PTC, there was no statistical difference with respect to lymph node involvement or metastasis (p=1.0 and p=.35, respectively). Other mutations detected include PAX8-PPARg (10.0%), ALK fusion (6.7%), RAS (3.3%), PTEN (3.3%), compound KIT and TSHR (3.3%), TRIM27-RET (3.3%), and other (3.3%). Notably, one patient presented with TRIM27-RET, which was associated with total lobe involvement, lymph node involvement, and distal metastasis. Conclusions: BRAF V600E and RET/PTC were the most prevalent molecular markers correlated with DTC in our predominantly Hispanic cohort. In comparison to BRAF V600E, RET/PTC was more prevalent in younger patients and was associated with a greater tumor size. We did not find any statistically significant differences with respect to age, tumor size, lymph node involvement, or metastasis between the aforementioned molecular markers. Incorporating molecular testing to supplement malignancy evaluation may improve clinical and surgical management for pediatric patients with DTC. Presentation: Thursday, June 15, 2023

Index of consciousness monitoring during general anesthesia may effectively enhance rehabilitation in elderly patients undergoing laparoscopic urological surgery: a randomized controlled clinical trial

BackgroundBased on electroencephalogram (EEG) analysis, index of consciousness (IoC) monitoring is a new technique for monitoring anesthesia depth. IoC is divided into IoC1 (depth of sedation) and IoC2 (depth of analgesia). The potential for concurrent monitoring of IoC1 and IoC2 to expedite postoperative convalescence remains to be elucidated. We investigated whether combined monitoring of IoC1 and IoC2 can effectively enhances postoperative recovery compared with bispectral index (BIS) in elderly patients undergoing laparoscopic urological surgery under general anesthesia.MethodsIn this prospective, controlled, double-blinded trail, 120 patients aged 65 years or older were arbitrarily assigned to either the IoC group or the control group (BIS monitoring). All patients underwent blood gas analysis at T1 (before anesthesia induction) and T2 (the end of operation). The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administered to all patients at T0 (1 day before surgery) and T4 (7 days after surgery). Serum concentrations of C-reactive protein (CRP) and glial fibrillary acid protein (GFAP) were assessed at T1, T2, and T3 (24 h after surgery). Postoperative complications and the duration of hospitalization were subjected to comparative evaluation.ResultsThe incidence of postoperative cognitive dysfunction (POCD) was notably lower in the IoC group (10%) than in the control group (31.7%) (P = 0.003). Postoperative serum CRP and GFAP concentrations exhibited significant differences at time points T2 (CRP: P = 0.000; GFAP: P = 0.000) and T3 (CRP: P = 0.003; GFAP: P = 0.008). Postoperative blood glucose levels (P = 0.000) and the overall rate of complications (P = 0.037) were significantly lower in Group IoC than in Group control.ConclusionThe employment of IoC monitoring for the management of elderly surgical patients can accelerate postoperative convalescence by mitigating intraoperative stress and reducing peripheral and central inflammatory injury.Trial registrationChinese Clinical Trial Registry Identifier: ChiCTR1900025241 (17/08/2019).

Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice.

Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.