Minor Surgery Research Articles

A new nomogram for predicting extraurothelial recurrence in patients with upper urinary tract urothelial carcinoma following radical nephroureterectomy

PurposeWe sought to develop and validate a nomogram for predicting extra-urinary recurrence (EUR) following radical nephroureterectomy (RNU) in patients with upper urinary tract urothelial carcinoma (UTUC).MethodsData from 556 UTUC patients post-RNU at the First Hospital of Jilin University were retrospectively analyzed. These patients were categorized into a training group (n=389) and a validation group (n=167). Variables significantly associated with prognosis were identified using univariate Cox regression and most minor absolute shrinkage and selection operator (LASSO) analysis. These independent predictors were incorporated into the nomogram to estimate extra-urinary recurrence-free survival (EURFS). Validation of the nomogram involved ROC curves, calibration plots, and decision curve analysis (DCA). Patients were stratified into two risk categories based on their nomogram scores to compare EURFS using the Kaplan-Meier method.ResultsEight predictors were identified: T-stage, N-stage, tumor grade, local and nerve invasion, preoperative hemoglobin level, neutrophil-to-lymphocyte ratio (NLR), and creatinine, all proving to be independent predictors of EUR. A nomogram was created based on these eight factors, and using the ROC, calibration curves, and DCA, good prediction results were shown in both the training and validation groups. The training and validation groups also showed reliable predictive performance. In particular, there was a significant difference in survival between the high-risk and low-risk groups (P<0.0001). We have also built a network calculator that calculates patient survival time. The URL is https://haowu24.shinyapps.io/dynnomapp.ConclusionA nomogram for predicting distant metastases in UTUC patients was successfully developed, and its accuracy, reliability, and clinical value were demonstrated. This new tool helps to improve the clinical management of UTUC cases.

The role of ingrown hairs in persistent kerion of children: A clinical study.

Tinea capitis, a common public health problem in developing countries, has severe forms such as kerion. However, the underlying mechanisms and standard treatments for persistent cases of tinea capitis or kerion remain controversial. In this work, we investigate the ingrown hairs and corresponding treatment in persistent kerion of children. Children with persistent kerion were enrolled among 312 cases of tinea capitis at the Department of Dermatology, Hangzhou Third People's Hospital from January 2020 to June 2024. The presence of fungal infection was ascertained by direct microscopic examination under calcofluor white staining and routine culture. The structure of the ingrown hairs was observed directly by a dermatoscope, which was subsequently extracted using sterile tools. A total of six cases of persistent kerion among 312 cases of tinea capitis were enrolled. Ingrown hairs were ascertained under dermatoscopy and extracted by minor operation. Except for one patient who continued oral terbinafine, the other five cases were cured by removal alone. Ingrown hairs, induced by fungal infection, may be an aggravating factor of persistent course of tinea capitis. Our study demonstrated that the presence of ingrown hairs could be confirmed through direct dermatoscopy, and patients experienced significant improvement following removal treatment under dermatoscopy.

A Qualitative Assessment of Adolescent Symptom Report and Caregiver Concordance Following Outpatient Surgery

Objectives: Limited data exist regarding recovery from surgery from the adolescent’s perspective, or data regarding concordance between adolescent and caregiver symptom report preventing appreciation of adolescent needs and hindering the provision of appropriate care. Methods: We conducted semi-structured interviews with adolescents ages 12-17 and a parent caregiver two weeks following a variety of outpatient elective surgeries about recovery symptoms. We used latent manifest content analysis to analyze interview data. Caregiver-adolescent response concordance was assessed using Cohen’s Kappa (κ). Results: Interviews were conducted with 31 adolescent-caregiver pairs (median age: 15y). Fifty-eight percent of adolescents and 84% of caregivers were female; 71% of adolescents were white. Twenty-three percent of children reported severe pain, some of which was not expected given the surgery. Severe pain was associated with nausea (71%, P= 0.002), pain-related sleep disturbance (86%, P= 0.007), and severe anxiety (43%, P= 0.008). Fatigue was also common (58%), but not associated with severe pain (P = 0.484) or sleep disturbance (P = 0.577). Thirty-nine percent reported anxiety; 32% experienced anger/frustration. Caregiver-adolescent concordance was only substantial for severe pain (κ = 0.71) and anger/frustration (κ= 0.67). Caregiver report also often included psychological symptoms not reported by their children, with qualitative evidence supporting caregiver accuracy. Discussion: Adolescents may experience significant physical symptoms such as pain and fatigue, even after minor surgeries. Fatigue symptoms may be unrelated to pain or sleep. Caregiver report of adolescent psychological symptoms may be necessary to gain a complete understanding of those symptoms in this population.

Risk Factors for Increased Opioid Use During Postoperative Intensive Care.

In the ICU, opioids treat pain and improve ventilator tolerance as part of an analgosedation approach. Identifying predictors of opioid consumption during the ICU course might highlight actionable items to reduce opioid consumption. To identify risk factors for opioid use during a postoperative ICU course. Patients enrolled in the Michigan Genomics Initiative single-center prospective observational cohort study completed baseline preoperative sociodemographic and mental/physical health questionnaires and provided blood samples for genetic analysis. Included patients were 18 years old and older, admitted to ICU postoperatively, and received opioids postoperatively. The primary outcome was ICU mean daily oral morphine equivalent (OME) use. The association between OME and phenotypic risk factors and genetic variants previously associated with pain were analyzed through univariable and multivariable linear regression models. The cohort consisted of 1865 mixed-surgical patients with mean age of 56 years (sd, 15 yr). Preoperative opioid users were more likely to continue to receive opioids throughout their ICU stay than opioid-naive patients. OME (log10 scale) was most strongly associated with ICU mechanical ventilation (β = 0.27; 95% CI, 0.15-0.38; p < 0.0001; effect size 1.85 for receiving > 24 hours of mechanical ventilation), preoperative opioid use (β = 0.22; 95% CI, 0.16-0.29; p < 0.0001; effect size 1.67 for receiving preoperative opioids), major surgery (β = 0.21; 95% CI, 0.12-0.30; p < 0.0001; effect size 1.62 compared with minor surgery), and current/former illicit drug use (β = 0.12; 95% CI, 0.01-0.23; p = 0.04; effect size 1.30 for drug use). Younger age, centralized pain, and longer anesthetic duration were also significantly associated with OME but with smaller effect sizes. Selected genetic variants (FKBP5, COMT, and OPRM1) were not associated with OME use. Mechanical ventilation and preoperative opioids were the strongest risk factors for postoperative ICU opioid consumption, whereas psychologic factors and genetic variants were not associated.

The Added Value of Sterility in Minor Surgical Procedures in Preventing Infection: A Systematic Review

Background: The necessity of maintaining sterility during minor surgical procedures is a debated topic due to concerns over the cost, environmental impact of sterile supplies, and the unclear benefits of sterility in minor surgical procedures. This review aims to evaluate the available evidence on this topic. Methods: A systematic review of studies comparing sterile and non-sterile techniques in minor surgical procedures was conducted. Databases searched included PubMed and Cochrane up to May 2024. Studies were selected based on predefined criteria. Results: A total of eight studies met the inclusion criteria. Non-sterility was mostly defined by the use of non-sterile gloves, whereas the remainder of the procedure was performed with the same technique as a sterile procedure. The analysis showed no significant difference in infection rates between sterile and non-sterile techniques. However, sterile techniques may reduce the risk of complications in specific contexts, such as in immunocompromised patients or in procedures performed in tissues deeper than subcutaneous fascia. Conclusions: The evidence suggests that for most minor surgical procedures, non-sterile techniques do not significantly increase the risk of postoperative infections. Further high-quality studies are needed to identify specific scenarios where sterility can be safely omitted to decrease surgical waste and costs without increasing the risk of infection.

Cost-effectiveness of surgical interventions in low-income and middle-income countries: a systematic review and critical analysis of recent evidence

BackgroundCost-effectiveness evidence is a critical tool to support resource allocation decisions. There is growing recognition that the development of benefit packages for surgical care should be guided by such evidence,...

How Much is Too Much? Evaluation of the Clinical Relevance of Routine Preoperative Investigations in American Society of Anaesthesiologist (ASA) Grades I and II Patients Undergoing Minor to Intermediate Elective Surgeries at Tertiary Care Teaching Hospital - Influence on Change in the Surgical Plan and Outcome

Abstract Background: In recent decades, experts have questioned the necessity of routine preoperative investigations due to their limited influence on perioperative management, higher expenses, postponed surgical procedures, patient anxiety resulting from false-positive results for minor operations and increased workload for laboratories. Objective: Our objective was to systematically evaluate the impact of pre-operative investigations on the treatment of patients opting for elective procedures. The study aimed to evaluate the impact of pre-operative investigations and peri-operative management on elective surgeries of the American Society of Anesthesiologists (ASA) physical status classification grades I and II, identifying common inappropriate investigations and assessing the impact of abnormal results on patient management. Materials and Methods: We conducted a prospective, cross-sectional, clinical, observational, single-centre study from February 2020 to March 2021 on 500 cases in the General Surgery Department of Tertiary Care Teaching Hospital. This study assessed the importance of pre-operative investigations in low-risk patients undergoing low-grade elective general surgical procedures. We recruited consecutive patients from the surgery wards of the institute, who fulfilled the inclusion criteria and obtained informed written consent for anaesthesia, surgery and participation in the study. Demographic data, the type of investigation conducted and test results were noted. We followed up with patients who had abnormal test results to record the consequences of the abnormality, such as the postponement of surgery and the requirement for additional investigations. Pre-operative transfusion, change in the management plan and change in the anaesthesia plan were recorded. Results: In the current study, the age of the patients ranged from 20 years to 45 years, and the mean age of the patients was 32.208 ± 9.16. The age group of 20–30 years was the commonest, being 158 (31.6%) patients. Out of 500 patients, 296 (59.2%) patients were males and the remaining 204 (40.8%) were female patients. Out of 500 tests, 44 (8.8%) had abnormal results. Most of the changes in our study were based on abnormal ECG findings. Out of a total of 500 surgical procedures performed, 497 (99.4%) were carried out without any difficulty, with two (0.4%) postponed due to abnormality in the pre-operative investigations and one (0.2%) cancelled. A total of 490 (98%) patients did not have any post-operative complications. Only ten (2%) patients developed post-operative complications, and out of those, only one (0.1%) had some abnormality in the pre-operative investigations. Conclusion: Preoperative laboratory investigations do not significantly influence the surgical outcome of the patients belonging to ASA grades I and II.

Perioperative fluid management: evidence-based consensus recommendations from the international multidisciplinary PeriOperative Quality Initiative

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

Interleukin-6 Receptor Gene rs1800795 Polymorphism and Expression of Interleukin-6 in Gingival Tissue in Patients with Periodontitis.

Periodontitis is a multifactorial inflammatory disease. This chronic periodontal disease is caused by a bacterial infection in the gums, which triggers a host inflammatory response. To eliminate the bacterial infection, immune response mechanisms are activated, leading to inflammation and damage to the periodontal tissues. This process involves many cytokines, including IL-6, a cytokine with antibacterial properties. An ongoing bacterial infection in the periodontal tissues leads to its excessive production, which increases inflammation. In this study, we examined IL-6 receptor gene rs1800795 polymorphism in patients with periodontitis in comparison with healthy subjects, as well as the correlation between rs1800795 genotypes and clinical parameters. Additionally we examined the expression of IL-6 in gingival tissue in patients with periodontitis and control subjects, as well as the correlation between gingival expression of IL-6 and clinical parameters. This study included 200 patients with periodontitis and 158 healthy subjects as the control group. Biopsy specimens of gingival tissue in which IL-6 expression was detected were taken from 14 patients with periodontitis and 8 controls who had undergone minor surgery. There were no statistically significant differences in the distribution of IL-6 rs1800795 genotypes and alleles between patients with periodontitis and control subjects. There were also no statistically significant correlations between IL-6 rs1800795 genotypes and clinical parameters in patients with periodontitis. There were no differences in IL-6 expression in the gingival tissue between patients with periodontitis and controls. There was also no correlation between IL-6 expression in the gingival tissue of patients with periodontitis and clinical parameters. In the control group, IL-6 expression in gingival tissue correlated negatively with the approximal plaque index, which reflects the size of bacterial plaques. The results of our study suggest a protective role for IL-6 against bacterial growth in the periodontal tissue. However, it should be noted that several parameters directly or indirectly affect the accumulation of bacterial plaque.

Real‐world effectiveness of eptacog beta in patients with haemophilia and inhibitors: A multi‐institutional case series

AbstractIntroductionThe management of bleeding events (BEs) in haemophilia A (HA) and B (HB) patients with inhibitors necessitates the use of bypassing agents. The recombinant factor VIIa bypassing agent eptacog beta has demonstrated efficacy at treating BEs and managing perioperative bleeding in adults in phase three clinical studies.AimTo provide real‐world descriptions of eptacog beta use for BE treatment in patients on emicizumab or eptacog beta prophylaxis.MethodsThis is a retrospective case series of 14 patients who received eptacog beta at seven haemophilia treatment centres, with HA (n = 11) or HB (n = 3) and inhibitors or anaphylaxis to factor replacement.ResultsTwenty‐four spontaneous and traumatic BEs are described (muscle hematomas, joint hemarthroses, port site, and epistaxis) involving 11 subjects. Eptacog beta was effective for acute bleed treatment as both first‐line therapy and for treatment of BEs refractory to eptacog alfa in 23/24 events. When eptacog beta was used for prophylaxis, 2/3 patients reported a decreased frequency of breakthrough BEs compared with prophylactic eptacog alfa and one patient experienced a similar frequency of breakthrough BEs compared with prophylactic activated prothrombin complex concentrate. Eptacog beta provided effective bleed control for three subjects who underwent minor surgical procedures. Treatment with eptacog beta was estimated to be 46%–72% more cost‐effective than eptacog alfa. No safety concerns or adverse events were reported.ConclusionsIn this case series, eptacog beta was safe, effective, and economical as first‐line therapy, treatment of refractory BEs, management of perioperative bleeding, or prophylaxis in haemophilia patients with inhibitors.

Local ketorolac infiltration for postoperative pain in open trigger finger surgery: a randomized controlled trial

BackgroundMultimodal analgesia is crucial for effective postoperative pain management in minor hand surgeries, enhancing patient satisfaction. The use of local wound infiltration with Ketorolac as an adjuvant pain management strategy is proposed for open trigger finger release surgery. This study aims to compare pain scores and functional outcomes between local wound infiltration with Ketorolac and oral non-steroidal anti-inflammatory drugs.MethodsThis study is a double-blind, parallel design, randomized controlled trials. Sixty-nine patients underwent trigger finger surgery between December 2021 and October 2022 were randomized into one of three groups: oral Ibuprofen alone group, local Ketorolac alone group and local Ketorolac with oral Ibuprofen group. The assessment included postoperative numeric rating scale (NRS) pain score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, mobility of proximal interphalangeal (PIP) joint. and complications.ResultsNRS pain scores during movement of the operated fingers were significantly lower at 6 h in local Ketorolac alone group and local Ketorolac with oral Ibuprofen group compared to oral Ibuprofen alone group. However, there were no significant differences between the groups in postoperative DASH scores, grip strength, mobility of PIP joints, and complications.ConclusionsLocal infiltration of Ketorolac as an adjunct in postoperative pain management has been shown to provide superior analgesia during finger movement within the initial 6 h following trigger finger surgery, in comparison to oral NSAIDs.Clinical trial registrationThaiclinicaltrials.org identifier: TCTR20210825002. Registered 25/08/2021. https://www.thaiclinicaltrials.org/show/TCTR20210825002

Laryngeal mask vs. laryngeal tube trial in paediatric patients (LaMaTuPe): a single-blinded, open-label, randomised-controlled trial.

In hypoxemic children with difficult airway, or for minor elective procedures, the use of a supraglottic airway device may be preferred to endotracheal intubation, whether with a laryngeal mask or laryngeal tube. Second-generation laryngeal masks may offer a better safety profile. Whether they should be preferred to laryngeal tubes is unknown. This study aimed to compare the efficacy and safety of second-generation laryngeal masks and laryngeal tubes in children. This randomised-controlled trial was conducted in a single university hospital in children <18 years undergoing elective anaesthesia in urology, minor paediatric surgery and gynaecology. Patients were 1 : 1 randomised to the laryngeal mask or laryngeal tube group. Children were allocated a second-generation laryngeal tube or a second-generation laryngeal mask as the primary airway device. The primary endpoint was insertion time. Secondary endpoints included first-attempt success, overall success and complications, which included hypoxia (SpO2 < 90%), laryngospasm, bronchospasm, aspiration and bleeding. In total, 135 patients were randomised, with 61 allocated to the laryngeal tube and 74 to the laryngeal mask group, with a median age of 5.4 and 4.9 years, respectively. Median insertion time was significantly longer in the laryngeal tube group (37 vs. 31 s; difference of medians: 6.0 s; 95% confidence interval: 0.0-13.0). The laryngeal tube had a significantly lower first-attempt (41.0%) and overall success rate (45.9%) than the laryngeal mask (90.5% and 97.3%, respectively). Those allocated to the laryngeal tube group had a higher ratio of complications (27.8%) compared to the laryngeal mask group (2.7%). This randomised-controlled trial reported that in children undergoing elective anaesthesia, the use of a laryngeal tube was associated with a longer insertion time.

EP335 - Audit of the Use of WHO Surgical Safety Checklist and its Awareness, Perception and Acceptability Amongst Theatre Personnel in a Tertiary Hospital in Sub-Saharan Africa

Abstract Aims The World Health Organization Surgical Safety Checklist (SSC) was developed to prevent perioperative adverse events. This study aimed to assess the utilization of the SSC and evaluate awareness and acceptability among theatre staff at a tertiary centre in sub-Saharan Africa. Methods We conducted a prospective audit of the SSC utilization during elective and emergency surgery, and a survey of awareness, perception and acceptability amongst theatre personnel (nurses, surgeons and anaesthetists) using a 15-item self-administered questionnaire between May 2022 and January 2023. Results 117 surgeries were observed for compliance with SSC and 81 theatre personnel took part in the survey. The checklist was used in 52.1% of all surgeries, 80% and 5.4% of major and minor surgeries respectively. In Time Out phase, activities were stopped in 23% of cases, and scrub nurses were asked relevant questions 31-47% of the time. Sign Out was the least completed phase. Three of five questions were asked 23-48% of the time. 28% of respondents who previously witnessed adverse events agreed that they could have been prevented by proper implementation of the SSC. 65.4% of members of the surgical team had not had any formal training on the SSC. There was no difference in its awareness, perception and acceptability based on profession of the respondents. Conclusion SSC was not fully utilized during the audit period. Lack of formal training may be contributory. There is broad awareness of SSC and its ability to prevent advert events. Key words: WHO, Surgical Safety Checklist, Awareness

Minor surgical procedures during immune tolerance induction in people with hemophilia A and inhibitors: results from the Brazilian Immune Tolerance (BrazIT) study cohort

IntroductionSurgeries are implicated in the development of anti-factor VIII (FVIII) neutralizing antibodies (inhibitors) in hemophilia A individuals with immune tolerance induction (ITI) treatment being the recommended therapy to eradicate these inhibitors. We evaluated the association of surgical procedures performed during ITI and treatment outcome. MethodsPatients were treated according to the Brazilian ITI Protocol with outcomes being defined as successful (i.e., recovered responsiveness to exogenous FVIII) and failed (i.e., unresponsiveness to exogenous FVIII thus requiring bypassing agents for bleeding control). Surgical procedures during induction therapy were managed following international recommendations. ResultsTreatment success rate was 68.7 % in 163 patients; 33 (20.2 %) were submitted to 43 (96 %) minor and two major surgeries. Personal, hemophilia, inhibitor, and treatment characteristics were similar between patients submitted to surgical procedures or not while on ITI; the success rates were 72.7 % and 67.7 % (p-value = 0.577), respectively. ConclusionNo association was found between having a minor surgical procedure and ITI treatment outcome.

Invasive procedures and surgery following etranacogene dezaparvovec gene therapy in people with hemophilia B

BackgroundLittle information regarding the management of invasive procedures in people with hemophilia B (HB) after undergoing gene therapy is available. Here, we report the management of invasive procedures in people with severe or moderately severe HB who had previously been treated with etranacogene dezaparvovec in the phase 2b and phase 3 HOPE-B clinical trials (NCT03489291 and NCT03569891). Objectives▪. MethodsThis retrospective analysis included invasive procedures performed within 3 and 2 years following a single infusion of 2 × 1013 gc/kg of etranacogene dezaparvovec in participants in the phase 2b and HOPE-B trials, respectively. Data for factor (F)IX dosing, duration of postoperative FIX use, FIX activity prior to invasive procedures, and postoperative bleeds were collected and analyzed. ResultsThe analysis included 64 procedures in 29 participants: 9 major surgeries, 24 minor surgeries, 11 endoscopies, 3 endoscopies with biopsy/polypectomy, and 17 dental procedures. Uncontaminated endogenous FIX activity corresponded to mild hemophilia or normal levels prior to 98% of all procedures, with a median endogenous FIX activity of 43.8 IU/dL (range, 3.1-113 IU/dL). All major surgeries were managed with exogenous FIX, 67% with ≤4 days of FIX infusion. Most minor surgeries (88%), endoscopies (82%), and dental procedures (94%) were managed with no or a single FIX infusion. Postoperative bleeds occurred after 1 minor surgery and 4 dental procedures. There were no symptomatic thrombotic events or FIX inhibitor developments. ConclusionEtranacogene dezaparvovec has the potential to facilitate perioperative management in people with HB by reducing the need for perioperative exogenous FIX and its associated risks.

Utility of routine preoperative laboratory testing for patients undergoing minor gynaecologic surgical procedures: interim analysis of their impact on intraoperative and postoperative complications.

Despite discouragement from many scientific societies, routine preoperative testing remains a common practice. Minor gynaecological surgery, being widely performed in everyday practice, represents an opportunity for implementing cost-reduction policies by avoiding unnecessary diagnostic assessments. To assess whether performing routine preoperative blood tests affects postoperative complications and cost-effectiveness in patients undergoing minor gynaecological surgery. An interim subgroup analysis of a retrospective study conducted by Fondazione Policlinico Gemelli (Rome) and Azienda Sanitaria Universitaria Friuli Centrale (Udine) was performed. Patients who underwent surgery under general anaesthesia were included. The studied population was divided based on the preoperative work up. Clinical data, surgical features and complications were collected. Intraoperative and postoperative complications, healthcare expenditure in two groups. Subgroup analysis included 1191 patients in Centre A (Rome) who underwent routine complete preoperative tests and 500 patients in Centre B (Udine), who underwent exams only if indicated. Population characteristics were similar in two groups. Postoperative complications were observed in 1.2% and 1.4% of cases in Group A and Group B, respectively (p=0.70). Severe complications occurred in 0.3% of cases in Group A and 0.4% in Group B. Group B showed a cost saving of approximately 70 Euros per procedure (p < 0.001). Preliminary data indicate that routine perioperative assessment did not reduce complication rates, hospital readmissions or surgical reinterventions. Given the high number of procedures, performing specific preoperative tests only when indicated may result in significant cost reduction. This study selectively highlights the potential benefits to overall public health expenditure that could be achieved through stricter adherence to guidelines on preoperative assessment in minor gynaecological surgery.

Clinical prediction rules for surgical site infection after minor surgery in general practice.

Surgical site infection (SSI) after dermatological surgery is associated with poor outcomes. Developing clinical prediction rules based on the predicted probability of infection might encourage guided prophylaxis and judicious prescribing. The purpose of this study was to develop a clinical prediction rule based on identified risk factors for SSI in a large general practice patient cohort. We examined a large, pooled dataset from four randomised controlled trials performed in a regional centre of North Queensland, Australia. Multivariable logistic regression identified a prediction model. Bootstrapping was used for internal validation. A scoring system was based on predicted probabilities of infection. The final prediction rule included age >55years and the anatomical site, histology and complexity of the excision. The area under the curve was 0.704. Our prediction rule encourages judicious use of prophylaxis in clinical practice.

Algorithm for the Treatment ofTip Malformation Combining a Clinical Qualitative Assessment and Specific Closed-Rhinoplasty Techniques Based on Retrospective Analysis of Pellegrini's Fellows 40 Years' Experience.

The aesthetic importance of nasal tip and the complexity of its surgical correction make the surgery of this area one of the most fascinating facial surgical procedures. Despite description of different sculpturing techniques to correct nasal tip defects, this surgery remains one of the most discussed and challenging aesthetic procedures. The objective of this study was to define an algorithm of treatment for nasal tip surgery based on 40-year experience on Caucasian patients evaluated by our proposed clinical qualitative assessment, who were treated by closed rhinoplasty. We retrospectively reviewed 19,643 Caucasian patients (15,266 females and 4,377 males) who underwent primary closed rhinoplasty from 1979 to 2019 due to different tip defects. The patients were evaluated by volume projection rotation (VPR) assessment. The surgical indications options, long-term aesthetic results and complications were analysed. 22% patients with minimal nasal defects were treated by non-delivery approach and 78% patients with important tip malformation by delivery approach. In all cases, the surgery was performed to reduce tip volume and modify tip projection and rotation based on the specific nasal defects. 67% patients, who needed important reduction of tip projection, were treated by tip-interrupting techniques. 88.7% patientsdeclared full satisfaction after surgery,and only 12.3% needed a requiring minor revision surgery during the 20 years follow-up. The proposed algorithm may be a useful tool to plan surgery. The use of an adequate technique depending on the evaluation of volume, projection and rotation may guarantee higher patients satisfaction and a stable long-term aesthetic result. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of classical music on light-plane anaesthesia and analgesia in dogs subjected to surgical nociceptive stimuli

The objectives of this prospective, randomized, blinded, crossover, experimental study were to detect the potential anaesthetic- and analgesic-sparing effects of classical music provided to dogs undergoing skin surgery, and to investigate the role of substance P as an intraoperative pain indicator. Twenty dogs were included, each subjected to three different treatments: Chopin music, Mozart music and no music. They were premedicated with acepromazine, butorphanol and meloxicam and anaesthetized with propofol and isoflurane. Fentanyl was used as rescue analgesia. The anaesthetic depth was monitored by using the bispectral index along with standard anaesthetic monitoring, and autonomic nervous system responses were used to monitor the adequacy of analgesia. Furthermore, measurements of substance P serum concentration were carried out. Dogs exposed to music required less isoflurane and fentanyl. Furthermore, a statistically significant effect of time on substance P concentration was observed regardless of exposure to music, and there was a significant interaction effect between different timepoints and the type of acoustic stimulus. Classical music seems to have an isoflurane and fentanyl sparing effect on dogs undergoing minor surgery. Following surgical stimulation, the serum substance P concentration increases rapidly, and thus appears to be a potentially useful pain indicator.

Perspectives on Neoadjuvant Clinical Trial Participation for Patients with Kidney Cancer: A Survey-Based Examination

Background: Kidney cancer is amongst the deadliest genitourinary malignancies. Neoadjuvant systemic therapy has the potential to improve survival and overall outcomes in select patients. Enrolling patients in trials of neoadjuvant treatment for kidney cancer is challenging, which limits neoadjuvant treatment development. Objective: This study aims to develop a better understanding of the barriers patients face in kidney cancer clinical trial participation, with a particular focus on neoadjuvant trials for renal cell carcinoma. Methods: From 2022–2023, we recruited participants with a history of kidney cancer through a Qualtrics survey that was sent to the Kidney Cancer Association (KCA) and Kidney Cancer Cure (KCCure) mailing lists and social media pages. Patient responses on demographics, clinical information, and perspectives were evaluated. Results: Ninety-four individuals completed the survey. Eighty-one percent of respondents reported not participating in clinical trials due to not being informed about potential applicable trials. Importantly, many (76%) respondents reported that prevention of cancer return was a highly important reason to participate in clinical trials. Most respondents reported a willingness to undergo a kidney biopsy (59%), and/or additional appointments (58%) and surgery delays. Conclusions: Increased patient awareness about clinical trials with the potential to delay cancer recurrence may increase patient participation in clinical trials. Clinical trial design, including additional appointments or interventions and/or minor surgery delays are not major barriers to trial participation.