Nonsurgical Setting Research Articles

Cardiac biomarkers prior to noncardiac surgery

Cardiac biomarkers, such as high-sensitivity cardiac troponin (hs-cTn) and brain natriuretic peptide (BNP) or N‑terminal prohormone of brain natriuretic peptide (NT-proBNP) are measured perioperatively to improve the prognosis and risk prediction. The European Society of Cardiology (ESC), European Society of Anesthesiology and Intensive Care (ESAIC) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI) have recently published guidelines on the use of cardiac biomarkers prior to surgery. This article provides an overview of the available evidence on perioperative troponin and BNP/NT-proBNP measurements. Current guideline recommendations are presented and discussed. MEDLINE, Cochrane and google.scholar were searched for relevant keywords. Titles and abstracts of identified papers were checked for relevance and published results were summarized. Guideline recommendations from the ESC, ESAIC and DGAI are presented, compared and evaluated based on the available literature. In addition, the significance of new perioperative cardiac biomarkers is discussed based on the existing evidence. The definitions, diagnosis and management of cardiovascular events in the perioperative context differ from those in the nonsurgical setting. The evidence for the measurement of hs-cTn and BNP/NT-proBNP is evaluated differently in the guidelines and the resulting recommendations are partly contradictory. In particular, recommendations for changes in perioperative management based on biomarker measurements diverge. The ESC guidelines propose an algorithm that uses preoperative biomarkers as the basis for additional cardiac investigations. In particular, invasive coronary angiography is recommended for patients with stable chronic coronary syndrome who have no preoperative cardiac symptoms but elevated biomarkers. In contrast, the ESAIC guidelines emphasize that the available evidence is not sufficient to use perioperative biomarker measurements as abasis for achange in perioperative management. Treating physicians should coordinate interdisciplinary (surgery, anesthesiology, cardiology) recommendations for clinical practice based on the aforementioned guidelines. If cardiac biomarkers are routinely determined in high-risk patients, this should be done in accordance with the ESC algorithm.

Management of Ocular Surface Inflammation with Persistent Epithelial Defects Using a Sutureless Human Amniotic Membrane Dehydrated Matrix: A Prospective Study Utilizing a Digital Ocular Surface Assessment Tool.

To report the outcomes of using a sutureless human amniotic membrane dehydrated matrix (HAMDM) in the management of a range of ocular surface conditions utilizing a digital ocular surface disease assessment tool. Two UK NHS Trusts - Queen Victoria Hospital Foundation Trust (East Grinstead and Maidstone) and Tunbridge Wells Trust (Kent) - prospectively treated patients with ocular surface disease with sutureless HAMDM. The patient cohort was assessed for resolution of epithelial defects, ocular surface inflammation, and best-corrected visual acuity pre- and posttreatment. Measurements of ocular surface inflammation and epithelial defect size were assessed using AOS digital imaging software, a validated tool for objective grading of bulbar conjunctival redness and measurement of corneal epithelial defects. A total of 47 applications of sutureless HAMDM on 46 eyes of 46 patients (25 male, 21 female, age 9-94 years) were assessed across various etiologies for an average of 24.0±14.1 days. Patients with limbal stem-cell deficiency (n=17), persistent epithelial defects (n=16), neurotrophic corneal disease (n=7), filamentary keratitis (n=2), corneal erosion (n=1), corneal thinning (n=1), ocular surface inflammation (n=1), and traumatic corneal laceration (n=1) were included in the study. Across all patents, 63% of eyes showed complete healing of epithelial defects and 32.6% of eyes showed partial resolution. The average rate of healing (wound closure) was 0.36 mm2 per day across the overall patient cohort, and the rate of healing in cases with complete resolution of epithelial defects was 0.41 mm2 per day. Inflammation across all four quadrants of the ocular surface remained stable. Visual acuity across the patient cohort remained stable (61%) and improved in 26% of patients (0.06±0.51 logMAR). Sutureless HAMDM application can be accomplished in just a few minutes and effectively treat a range of ocular surface disease in a clinical, nonsurgical setting. The AOS imaging software offered a quantitative methodology for measuring epithelial defect size and inflammation state.

Dietary vitamin C intake and changes in frequency, severity, and location of pain in older adults.

Oral vitamin C supplementation has been associated with lower risk of chronic postsurgical pain. However, the effect of dietary vitamin C on pain in a non-surgical setting is unknown. We aimed to investigate the association between dietary vitamin C intake and changes over time in chronic pain and its characteristics in community-dwelling adults aged 60+ years. We pooled data from participants of the Seniors-ENRICA-1 (n=864) and Seniors-ENRICA-2 (n=862) cohorts who reported pain at baseline or at follow-up. Habitual diet was assessed with a face-to-face diet history and dietary vitamin C intake was estimated using standard food composition tables. Pain changes over time were the difference between scores at baseline and follow-up obtained from a pain scale that considered the frequency, severity, and number of pain locations. Multivariable-adjusted relative risk ratios (RRR) were obtained using multinomial logistic regression. After a median follow-up of 2.6 years, pain worsened for 696 (40.3%) participants, improved for 734 (42.5%), and did not change for 296 (17.2%). Compared to the lowest tertile of energy-adjusted vitamin C intake, those in the highest tertile had a higher likelihood of overall pain improvement (RRR 1.61 [95% confidence interval 1.07-2.41],p-trend 0.02). Higher vitamin C intake was also associated with lower pain frequency (1.57 [1.00-2.47],p-trend=0.05) and number of pain locations (1.75 [1.13-2.70],p-trend=0.01). Higher dietary vitamin C intake was associated with improvement of pain and with lower pain frequency and number of pain locations in older adults. Nutritional interventions to increase dietary vitamin C intake with the aim of improving pain management require clinical testing.

Addressing the Cosmetic Resident Education Gap – a Junior Cosmetic Fellowship Program

Abstract Goals/Purpose Incorporating adequate aesthetic surgery training into integrated plastic surgery programs in the United States has remained a challenge for several decades.[1-4] Specifically, residents report low confidence in performing facial cosmetic procedures compared to breast and body contouring.[1-2] This becomes increasingly relevant in the setting of heightened specialty creep and the rise in demand for cosmetic procedures overall according to the 2022 ASPS procedural statistics which show a 19% increase in cosmetic surgery procedures compared to the pre-pandemic 2019 report.[5] In a survey of 257 residents, 26.4% felt confident performing a lower blepharoplasty, 25% performing a facelift, 16.5% performing an endoscopic brow lift, and 14% performing a rhinoplasty.[2] This resident-reported difficulty with facial cosmetic procedures has shown little progress over time in reported survey data despite an increase in minimum cosmetic case numbers and length of training. A comprehensive aesthetic training also includes exposure to non-surgical interventions such as neuromodulators, injectables, non-surgical body contouring and facial rejuvenation technology. Though non-invasive fat reduction (ie. cryolypolysis) and non-surgical skin tightening (ie. radiofrequency micro-needling) have increased in demand since 2019 (77% and 22%, respectively), residents rarely have hands-on exposure to these treatment modalities.[5] Several integrated plastic surgery programs have a dedicated year of professional development or research, providing an opportunity for programs to fill this gap between cosmetic surgery training and real-world demand. Methods/Technique A junior cosmetic fellowship curriculum was created at a single institution focused on increasing confidence in performing aesthetic surgery, exposure to non-surgical cosmetic procedures, and increasing exposure to the business side of private practice. The fellowship was designed for a single resident during the professional development year of integrated plastic surgery training, completed between the third and fourth clinical years. The junior fellow spent the year within a single, multi-office private aesthetics practice in both the surgical and non-surgical setting. Over the course of the first four months (July 2023 - October 2023), the clinical experience of the Stanford junior cosmetic fellow was queried. Analysis of surgical case volume and non-surgical patient load was performed. This was then used to project surgical cases anticipated to be completed by year end. This was compared to case log minimums for graduating integrated plastic surgery residents in the United States, an essential metric of assessing resident experience and competence. Financial analysis of the non-surgical treatments by the junior fellow was performed. Using the initial four-month data, projections were also estimated to determine profitability for the practice over the course of the year-long fellowship. Results/Complications Over the span of the initial four months, the junior cosmetic fellow completed 69 cases, 58% of which were breast / body and 42% of which were focused on facial rejuvenation. It is estimated that at completion of the fellowship, this projects to 207 cases, exceeding the cosmetic ACGME program requirements for graduation. Total sales generated by the junior fellow during the first four months were as follows: $22,802, $90,257, $78,563, and $75,084 USD. Therefore, total sales by year end are estimated to be $800,118 in non-surgical treatments – demonstrating expertise of the junior fellow in non-surgical procedures and also profitability for the practice. Conclusion Increasing resident comfort with aesthetic surgical and non-surgical procedures is imperative as the demand for cosmetics continues to rise. Here we highlight the creation of a junior cosmetic fellowship, designed for programs with a year of professional development in their plastic surgery curriculum, to bridge the gap of cosmetic resident education. This junior fellowship model increases overall resident comfort in aesthetics and experience with facial procedures, a known weakness in resident training. Also, the addition of a junior fellow has shown to be financially lucrative for a practice, encouraging private practice attendings to consider this teaching model. Beyond the scope of programs with a dedicated year for professional development, this fellowship model may encourage embedded fellowships or incorporating mini-fellowships of 3-6 months in aesthetic surgery into residency programs outside of the traditional chief resident cosmetic experience.

Variable practice is superior to self-directed training for laparoscopic simulator training: a randomized trial

BackgroundMastering laparoscopy is challenging—it requires specific psychomotor skills which are difficult to obtain in the operating room without potentially compromising patient safety. Proficiency-based training programs using virtual reality simulators allow novices to practice and develop their skills in a patient-safe learning environment. Variable practice leads to stronger retention and skills transfer in a non-surgical setting. The objective of this trial was to investigate if variable practice was superior to self-directed training.MethodsA randomized trial where participants (n = 36) were randomized to proficiency-based laparoscopic simulator training of basic skills using either variable practice or self-directed training, followed by a transfer test with proficiency-based training on a procedural task (a salpingectomy). All participants returned after a period of 3–5 weeks to perform a retention test. Results: The mean time to proficiency for the basic skills tasks were 119 min (SD: 93) for the variable practice group versus 182 min (SD: 46) for the self-directed training group (p = 0.015). The time to reach proficiency during the transfer test was 103 min (SD: 57) versus 183 min (SD: 64) for the variable practice group versus the self-directed training group, respectively (p < 0.001). The mean time to proficiency for the retention test was 51 min (SD: 26) and 109 min (SD: 53) for the variable practice group and self-directed training group, respectively (p < 0.001).ConclusionVariable practice is superior to self-directed training for proficiency-based laparoscopic training. With variable time to practice proficiency is reduced, there is higher transfer to a procedural task, and retention is improved.

Trends in newly diagnosed atrial fibrillation and oral anticoagulant use after cardiac surgery: a population-based analysis from Ontario, Canada

Abstract Background Post-operative atrial fibrillation after cardiac surgery is associated with an increased risk of death and ischemic cardiovascular outcomes. In the non-surgical setting, oral anticoagulation (OAC) is beneficial among patients with AF in reducing their risk of thromboembolism. The use of OAC for patients with post-operative AF after cardiac surgery is not well-defined in contemporary clinical practice - at a time when direct oral anticoagulants (DOAC) are commonly prescribed in the non-surgical setting. Purpose To examine trends in OAC use among patients with post-operative atrial fibrillation after cardiac surgery at a time when DOAC is commonly prescribed in clinical practice. Methods The study cohort consisted of consecutive patients (&amp;gt;65 years) who experienced post-operative AF within 90 days after coronary artery bypass grafting (CABG), isolated left-sided non-mechanical heart valve surgery (iValve), and combined CABG + valve surgery between 2008 and 2021, identified by a mandatory provincial registry of all patients undergoing cardiac surgery in Ontario, Canada. Key exclusion criteria included: patients with pre-existing AF, end-stage renal disease requiring dialysis, mechanical heart valves, left atrial appendage ligation, and those who required anticoagulation for non-AF indications. Prescription of OAC (warfarin or DOAC) within 90 days after discharge from surgery was collected via linkage with the Ontario Drug Benefits Plan. Results The overall cohort consisted of 45,571 patients, in whom 14,572 (32.0%) developed POAF after cardiac surgery. Rates of POAF were highest among patients who underwent combined CABG + valve surgery (44.3% in 2008 to 34.2% in 2021), followed by iValve (42.6% in 2008 to 37.3% in 2021), then followed by isolated CABG (27.6% in 2008 to 24.2% in 2021). Over the study period, there was a decrease in the rates of POAF among patients who underwent all three types of cardiac surgery (P[trend] &amp;lt;0.01). In 2021, rates of oral anticoagulation were highest among patients who underwent combined CABG + valve surgery (61.1%), followed by iValve (59.2%) and isolated CABG (42.0%). Among patients who underwent isolated CABG, there was a 9% increase in the rates of OAC use during the study period (P[trend] &amp;lt;0.001). On the other hand, rates of OAC use remained largely unchanged (Figure A) among patients who underwent iValve and combined CABG + valve surgery (P[trend] 0.24 and 0.26, respectively). Since 2018, DOAC accounted for 60-70% of all OAC prescriptions (Figure B). Conclusions Despite advances in surgical techniques and post-operative care, the rates of post-operative atrial fibrillation after cardiac surgery remain substantial. Prescription rates for OAC remain modest over the past decade, but DOAC is increasingly more commonly prescribed in this patient population. Randomized trials are needed to assess the risks and benefits of OAC, specifically DOAC, in this high-risk patient population.Figure AFigure B

Frailty and Inflammatory Bowel Disease: A Scoping Review of Current Evidence.

Frailty is increasingly recognized as an important concept in patients with Inflammatory Bowel Disease (IBD). The aim of this scoping review is to summarize the current literature on frailty in IBD. We will discuss the definition of frailty, frailty assessment methods, the prevalence of frailty, risk factors for frailty and the prognostic value of frailty in IBD. A scoping literature search was performed using the PubMed database. Frailty prevalence varied from 6% to 53.9%, depending on the population and frailty assessment method. Frailty was associated with a range of adverse outcomes, including an increased risk for all-cause hospitalization and readmission, mortality in non-surgical setting, IBD-related hospitalization and readmission. Therefore, frailty assessment should become integrated as part of routine clinical care for older patients with IBD.

Chest pain in patients recovering from noncardiac surgery: A retrospective analysis

Study objectiveChest pain is relatively common postoperatively. Myocardial infarction (MI) is one cause of chest pain after surgery, but chest pain also results from less severe conditions. Because of its potential severity, chest pain usually prompts the activation of Rapid Response Systems (RRS). While chest pain is a cardinal symptom of myocardial ischemia in the non-surgical setting, the significance and relevance of chest pain after noncardiac surgery remains unclear. DesignWe conducted a retrospective analysis of noncardiac surgical inpatients for whom postoperative chest pain triggered our multidisciplinary RRS. SettingSurgical wards at Cleveland Clinic, Cleveland, OH. PatientsPostsurgical patients after noncardiac surgery in whom the RSS system was activated for chest pain. InterventionsRRS specified interventions like ECG readings, troponin measurements, transfer to ICU. MeasurementsOur primary outcome was MI. Secondary outcomes included the proportion of patients who had an ECG performed, troponin measurements, echocardiography, cardiac catheterization, and were admitted to the Intensive Care Unit (ICU). Main results5850 surgical patients experienced postoperative chest pain and triggered an RRS activation between 2009 and 2019. A total of 3110 patients had troponin T measured within 6 h after RRS activation, and 538 of them (17%) had elevated troponin, meeting the Fourth Universal Definition criteria for MI. Additionally, 2 patients had ST-segment elevation infarction (STEMI) without troponin measurement. Among the 540 patients with MI, only 19 (3.5%) were diagnosed with a STEMI by ECG, 388 (72%) had echocardiography, 43 patients (8%) had cardiac catheterization, 8 patients (1.5%) required emergent cardiac surgery, and 424 (79%) were admitted to an ICU. ConclusionChest pain is a serious clinical sign, often indicating a postoperative myocardial infarction, and therefore should be taken seriously. Troponin screening should be routinely considered in postsurgical patients who report chest pain.

Informal payments and patients’ perceptions of the physician agency problem: Evidence from rural China

Informal payment for medical services is a common phenomenon in China. Patients make informal payments, in cash or in kind, to physicians in addition to official charges billed for medical services. This paper assesses the associations between patients' perceptions of the physician as an agent for the patient's interests (physician agency problem) and informal payment behavior. Using data of 24,000 and 6700 rural households respectively from the Health Development of Rural China Program database (collected in 2008) and Ningxia data source (collected in 2015), we find that patients' concern about physician agency problems is significantly associated with informal payments. The data shows that patients are more likely to make informal payments when they show low trust towards their physicians. For example, in the surgical cases, among patients who strongly distrusted the physicians, 17.9% (95% confidence interval [CI]:]: 13.5, 22.3) initiated informal payments, compared to 8.0% (95% CI: 5.1, 10.9) who expressed “strong trust” in their physicians. Poor communication was also significantly associated with an increase in the informal payment rate. For example, in the non-surgical setting, among the patients who rated the physicians' explaining skills as “poor,” 5.9% (95% CI: 5.0, 6.9) of them made informal payments, significantly higher than the patients who rated “excellent” (of whom 1.8% made informal payments 95% CI, 0.9, 2.7). In this study, we provide an explanation for this finding: patients may initiate informal payments to physicians in order to mitigate the physician agency problem. It suggests that to mitigate informal payments, improving alignment between doctors' incentives and patients' interests would be essential.

Development of a multiphasic, cryptic screening protocol for body dysmorphic disorder in cosmetic dermatology

BackgroundThe incidence of body dysmorphic disorder in cosmetic dermatology is high. Even though treating patients with this disorder may worsen symptoms and is fraught with potential complications, screening is low, due in part to lack of knowledge of the disorder, as well as inadequate screening tools.ObjectivesTo verify the probability of body dysmorphic disorder in a nonsurgical esthetic setting and determine the effect of a multiphasic screening protocol on mitigating poor outcomes in high‐risk patients.MethodsA multiphasic screening protocol for body dysmorphic disorder was distributed to a total of eight esthetic clinics in the United States. Practitioners administered an anonymous, cryptic prescreening form to all new, incoming patients aged ≥ 18 to ≤ 65 years from June 1, 2019, through September 1, 2019, followed by a second, more extensive screening questionnaire. Patients with suspected or subclinical body dysmorphic disorder could be refused treatment.ResultsA total of 734 initial screenings were recorded over 16 weeks. Of these, 4.2% (31/734) proceeded to the secondary screening phase; 29% (9/31) subsequently screened positive for body dysmorphic disorder. Practitioners refused to treat 77.8% (7/9) of positive screenings. Two patients out of seven who tested positive underwent a third screening and were subsequently treated with positive outcomes.ConclusionsUse of a cryptic screening protocol enables identification of individuals at risk for BDD and encourages open and continuous communication between patient and provider.

2820 A Retrospective Study to Assess Safety and Efficacy of the HET Bipolar Ligator System for the Treatment of Grade I and II Internal Hemorrhoids

INTRODUCTION: Hemorrhoidal disease is a common condition, affecting about 80% of all Americans at some point in their life. There are two types of hemorrhoids: internal and external hemorrhoids. The internal hemorrhoids are further classified into four grades depending on their presentation. The HETTM Bipolar Ligator System is a nonsurgical safe and easy procedure that uses sterile, single-use bipolar forceps with a tapered tubular configuration for the treatment internal hemorrhoids. This study evaluated the efficacy and safety of the HETTM Bipolar Ligator System for the treatment of grade I and grade II hemorrhoids with the potential idea to improve overall patient care. METHODS: Primary goal was to evaluate the efficacy and safety of the HETTM Bipolar Ligator System for the treatment of grade I and grade II hemorrhoids. Using a chart review, all of the patients who had received elective treatment for grade I or grade II internal hemorrhoids with the HETTM Bipolar Ligator System from April 2013 to November 2016 in our community hospital. A total of 100 patients were studied for treatment with the HETTMsystem. RESULTS: Total of 100 patients received treatment with the HETTM system, 39 patients were male, and 61 were female. The mean age of the patients was 59 years. 27% of the patients complained of mild bleeding, 49% of moderate bleeding and 24% of severe bleeding. 31% of the patients complained of daily bleeding, 53% complained of bleeding at least once a week and 16% complained of bleeding less than once a week. 37% of patients had grade I hemorrhoids while 63% had grade II hemorrhoids. Only 11% of the patients reported pain at levels 1–2 (out of 5) immediately after the procedure, and in 15% of the patients, mild bleeding was observed. After the six-month follow-up period (Figure 3), 96% of the patients had a resolution of bleeding (primary goal). Lastly, all of the patients reported a high level of satisfaction with the procedure. CONCLUSION: All other hemorrhoidal treatments including rubber band ligation, sclerotherapy, bipolar diathermy, cryotherapy and laser photocoagulation were associated with complications such as postoperative pain and bleeding or required multiple treatments to provide relief. The HETTM ligation device is a novel treatment option for symptomatic grade I and grade II hemorrhoids. It is simple, cost effective, safe and highly effective in resolving bleeding hemorrhoids in a single non-surgical ambulatory setting.

Opioid-Induced Hyperalgesia in the Nonsurgical Setting: A Systematic Review.

Opioid-induced hyperalgesia (OIH) is a phenomenon that causes an increased pain sensitization and perception of pain to noxious stimuli secondary to opioid exposure. While this clinical effect has been described in the surgical setting, it is unclear if OIH occurs in the nonsurgical setting. To review the available literature which evaluated OIH in nonsurgical settings. A comprehensive literature search was performed using PubMed (January 1946-July 2017) using a variety of keywords for OIH. This review included randomized controlled trials with objectives to identify OIH in the nonsurgical setting. The clinical outcomes of interest were identification of OIH, adverse events, and impact of OIH on opioid consumption. The search identified 8 studies that fulfilled the criteria. Six studies enrolled healthy male volunteers, 1 study used chronic low-back patients, and another used heroin-dependent treatment-seeking adults. Studies used various opioids and dosages, including remifentanil, alfentanil, fentanyl, morphine, methadone, and buprenorphine. Three primary experimental pain induction models were used to evaluate for OIH. Measured outcomes included hyperalgesia area, pain threshold, and pain tolerance. All 5 studies that used the electrical stimulation model identified OIH as a significant outcome. However, only 2 of 5 studies using the cold pressor model and 1 of 3 studies using the heat pressor model identified OIH. None of the trials explored clinical outcomes, such as effects on opioid consumption. Most included studies identified OIH as a significant outcome within the nonsurgical setting. However, due to conflicting conclusions and various limitations, the clinical impact of OIH could not be assessed. Clinicians should monitor for effects of OIH in the nonoperative setting because there is insufficient evidence from the available literature to conclude that OIH is consistently observed in this setting.

Blood Pressure Coefficient of Variation and Its Association With Cardiac Surgical Outcomes.

Multiple studies completed in the ambulatory nonsurgical setting show a significant association between short- and long-term blood pressure variability and poor outcomes. However, perioperative blood pressure variability outcomes have not been well studied, especially in the cardiac surgical setting. In this study, we sought to assess whether systolic and mean arterial blood pressure variability were associated with 30-day mortality and in-hospital renal failure in patients undergoing cardiac surgery requiring cardiopulmonary bypass. Furthermore, blood pressure variability has not been evaluated specifically during each phase of surgery, namely in the pre-, intra- and postbypass phases; thus, we aimed also to assess whether outcomes were associated with phase-specific systolic and mean arterial blood pressure variability. All patients undergoing cardiac surgery from January 2008 to June 2014 were enrolled in this retrospective, single-center study. Demographic, intraoperative, and postoperative outcome data were obtained from the institution's Society of Thoracic Surgery database and Anesthesia Information Management System. Systolic and mean arterial blood pressure variability were assessed using the coefficient of variation (CV). The primary outcomes were 30-day mortality and in-hospital renal failure in relation to the entire duration of a case, while the secondary outcomes assessed phase-specific surgical periods. In an effort to control the family-wise error rate, P values <.0125 were considered significant for the primary outcomes. Of the 3687 patients analyzed, 2.7% of patients died within 30 days of surgery and 2.8% experienced in-hospital renal failure. After adjusting for significant covariates, we found a statistically significant association between increasing CV for systolic blood pressure (CVSBP) and 30-day mortality and in-hospital renal failure. For every 0.10 increase in CVSBP, there was a 150% increase in the odds of death (odds ratio, 2.50; 95% confidence interval, 1.60-3.92; P < .0001) and there was a 104% increase in odds of experiencing renal failure (odds ratio, 2.04; 95% confidence interval, 1.33-3.14; P = .001). The association with mortality was driven primarily by the prebypass period, because the association between CVSBP and mortality during the prebypass phase was significant (P = .01), and not during the postbypass phase (P = .08). There was no significant association between CV for mean arterial blood pressure and either death or renal failure during any period of surgery, including the bypass phase. Increasing systolic blood pressure variability was associated with 30-day mortality and development of renal failure, with surgery phase-specific relationships observed. Further research is required to determine how to prospectively detect blood pressure variability and elucidate opportunities for intervention.

BDNF/HMW-HA complex as an adjunct to nonsurgical periodontal treatment of ligature-induced periodontitis in dogs.

Recently, brain-derived neurotrophic factor (BDNF)/high molecular weight hyaluronic acid (HMW-HA) complex with flap surgery has been shown to promote periodontal tissue regeneration. The objective of this study was to evaluate the effects of local subgingival application of BDNF/HMW-HA complex adjunctive to scaling and root planning (SRP) on ligature-induced periodontitis in dogs. The dogs were divided into four treatment groups: no treatment (control), SRP alone, SRP followed by local application of HMW-HA (SRP+HMW-HA), and SRP followed by local application of BDNF (500μg/ml)/ HMW-HA complex (SRP+BDNF/HMW-HA). HMW-HA or BDNF/HMW-HA complex was topically applied to periodontal pockets using a syringe without surgery. Two weeks after treatment, clinical parameters (gingival index, clinical attachment level, periodontal pocket depth and bleeding on probing) were recorded and specimens were collected from anesthetized animals for histological analysis. The SRP+BDNF/HMW-HA group showed significant improvement in all clinical parameters compared to other treatment groups. Histologic analysis showed greater suppression of apical migration of epithelial tissue and milder inflammatory cell infiltration in the SRP+BDNF/HMW-HA group than in the other treatment groups. Furthermore, new cementum and alveolar bone were regenerated, and collagen fibers were inserted into them in the SRP+BDNF/HMW-HA group. BDNF/HMW-HA complex as an adjunct to nonsurgical periodontal treatment has the potential to reduce excess inflammation. Further investigation will be needed to clarify periodontal tissue regenerative effects of BDNF/HMW-HA complex in a nonsurgical setting.

230P Experience with the implant of vascular access devices by medical oncologists in a non-surgical setting

Background: Totally implantable central venous catheters are widely used in the management of patients (pts) with malignant diseases to facilitate drug delivery for the new therapeutic protocols. These are based on continuous administration and higher doses of chemotherapeutic agents with relative phlebitis problems and supportive treatment. Staff of our department, specially trained in the routine implantation of central venous accesses were in charge of the procedure. The technique was carried out under local anesthesia in a special suite of day hospital, under strict aseptic measures without fluoroscopic control. Methods: From Sep 94 to January 2017, 1665 devices (port-a-cath systems [PS]) were implanted in 1627 pts, with a median age of 50.5 yr (range 14–81), and median K. I. 70% (50–100), female 982/male 683. Venous access: right interior jugular 983, left subclavian 316, right subclavian 333, left interior jugular 33. A thorax X-ray was performed after each procedure and in 216 pts prophylactic antibiotics were given. Results: The venous access remained implanted a median of 438 days (1- +2210). Complications occurred in 266 placements (16%): infections 116 (7%); deep venous thrombosis 66 (4%) obstruction 10 (0.6%); malpositioned 16 (2%); fractures/migration 28 (1.7%); pneumothorax 6 (0.32%); local skin necrosis 7 (0.6%). 520 devices were removed, 347 (66%) after completing planned therapy, and 173 (34%) due to complications [Infections (92), migration (22), malposition (12), venous thrombosis (26), obstruction (11) and skin necrosis (10)]. Cost-effectiveness of venous catheters in a non-surgical setting compared with devices implanted by interventional vascular radiologists in operating room turned out to be 1000 euro cheaper for each device. Conclusions: Our experience suggests that implant of vascular access devices by medical oncologist in a non-surgical setting has similar or even less complications and is more cost effective with regard to radiology suite and operating room placement procedures. Legal entity responsible for the study: SESPA Funding: Has not received any funding Disclosure: All authors have declared no conflicts of interest.

Lateral Atlantoaxial Osteoarthritis: A Narrative Literature Review.

Lateral atlantoaxial osteoarthritis (AAOA), or C1-C2 lateral mass arthritis (LMA), is an unfamiliar degenerative cervical disease with a clinical presentation that markedly differs from subaxial spondylosis. The prevalence of LMA in the nonsurgical outpatient setting is 4%. Risk factors include age and occupation. The typical patient is between 50 and 90 years old, presents with upper cervical or occipital pain, has limited rotation, and has pain provocation during passive rotation to the affected side. Pain stems from degeneration of the lateral C1-C2 articulation and may be referred or radicular, through the greater occipital nerve. Although there is no consensus on diagnostic work-up, the disease is classically seen on the open-mouth odontoid radiograph. Computerized tomography, magnetic resonance imaging, bone scan, and diagnostic injections are also useful. Initial treatment is conservative, and upwards of two-thirds of LMA patients obtain lasting relief with noninvasive measures and injections. In patients with severe, recalcitrant pain, limited C1-C2 fusion offers satisfactory and reliable relief. The goals of this review article are to provide a synthesis of the literature on LMA, to offer a treatment approach to LMA, and to identify problems with the current state of knowledge on LMA.

Perioperative vascular events and myocardial injury after noncardiac surgery in vascular surgery: An overview of the current emerging evidence and guidelines

Vascular surgery is considered a high-risk noncardiac surgery. It is associated with an increased risk of cardiovascular events in the perioperative period. Preoperative assessment of risk using validated scales such as Revised Cardiac Risk Index, helps informing patients, surgeons, and anesthetists on the potential risk of cardiovascular events. Cardiac biomarkers, such as NT pro-brain natriuretic peptide (pro-BNP)/BNP, improve the sensitivity of these scales, in predicting potential serious perioperative cardiovascular outcomes. It is cost effective and quicker than other invasive or noninvasive procedures, usually done before any vascular surgery. Several interventions have been tested in trials for potentially preventing an event, but none have given good quality evidence for benefit, except the use of statins. Postoperatively, use of drugs to prevent a cardiovascular event has not been as effective as in the nonsurgical setting (aspirin, β-blockers, α2agonists, and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers). Monitoring of highly sensitive troponins better predicts 30-day mortality in patients undergoing any noncardiac surgery. This event is called myocardial injury after noncardiac surgery (MINS) or in short MINS. Currently, MINS is not detected in over 75% of vascular surgery patients as it is not routinely performed. As per the evidence reviewed in this article and as recommended by the Canadian Cardiovascular Society Guidelines, it is imperative we monitor all patients aged above 45 years undergoing vascular surgery. Even though there is no evidence for an effective intervention of MINS, detections help in better monitoring of the patient and initiating effective secondary prevention treatment, as indicated.

Three Factor Prothrombin Complex Concentrates in Cardiac Surgery: A Novel Algorithmic Approach to Perioperative Bleeding

Background: Three component prothrombin complex concentrates (PCCs) are currently approved to treat bleeding associated with Hemophilia B, and 4 component PCCs for warfarin reversal. They are increasingly used to treat bleeding in cardiac surgery patients. High dose PCC administration in the non-surgical setting has been associated with thrombotic complications, likely due to increased Factor II (Prothrombin) levels. We hypothesized that the use of low dose 3 factor PCCs (Profilnine, Grifols, CA) reduces bleeding following cardiopulmonary bypass without increasing the incidence of postoperative thrombotic complications.Methods: After IRB approval, a retrospective chart review of patients who underwent cardiac surgery and received Profilnine for refractory bleeding from February 2014 to February 2015. Demographic information, preoperative lab values, blood product use before and after PCC, use of rFVIIa, chest tube output and venous and arterial thromboembolic complications were collected. PCC was dosed according to an institutional perioperative bleeding algorithm (Figure 1) after approval by one of the senior authors (KG, JL or IW).Results: 114 patients received Profilnine¨ (Grifols, CA) for postoperative bleeding following cardiac surgery. The most common procedure that required PCC administration was elective aortic reconstruction (61, 57%) followed by acute aortic dissection (13, 12.1%). The mean dose of PCC was 15.8±7.1 IU. The chest tube output for the first hour after arriving in the ICU 150.8±214.0 ml and quickly decreased to 89.5±122.1 ml in the second hour. The mean total blood product transfusion was 12.4±9.9 units prior to PCC dose and 5±6.3 units post dose. The difference is represented in Figure 2 and was found to be statistically significant on a paired t-test. (p <0.0001). Only 4 patients (3.7%) of the patients had to return to the operating room for a re-exploration.Four patients (3.7%) had a cerebrovascular infarction in the postoperative period, of which two patients had undergone ventricular assist device (VAD) insertions, one had an aortic reconstruction and one had central ECMO cannulation performed following a STEMI. The patient with the aortic reconstruction received a higher dose of PCC (3000 Units or 33.5U/kg) and recombinant VIIa. One patient, who had a VAD inserted, had a pulmonary embolism. They received a low dose of PCC (13.8U/kg) did not receive factor VIIa. The post dose factor II activity level for this patient was 64%. Six patients (5.6%) had deep vein thrombosis diagnosed by venous doppler ultrasound. Four of these patients had received factor VIIa after PCC administration.Post dose prothrombin levels were measured in 20 patients, with a mean of 85.9%(±19.3%).The mean PCC dose in this group was 16.3 (±9.0) IU/kg per actual body weight, and 20.2 (±12.1) IU/kg per ideal body weight. Post dose factor II levels were plotted against PCC dose/kg in this group. The median factor II level was 87% (Figure 3). 12 out of these 20 patients received factor VIIa as part of the algorithm, and no postoperative thrombotic complications were reported in this subgroup.Conclusions: Our initial findings from this ongoing study revealed a reduction of total blood products transfused after administration of PCC compared to before administration. Our series is reporting a higher rate of thrombotic events. While some of these are associated with factor VIIa administration following the PCC dose, most are likely to be multifactorial in etiology and were well tolerated. Additional randomized studies are needed to determine the safety and efficacy of PCCs in cardiac surgical patients. [Display omitted] [Display omitted] [Display omitted] DisclosuresGhadimi:Portola Pharmaceuticals: Other: KG is a Co-Investigator in a prospective, open-label study of Andexanet Alfa in patients receiving factor Xa inhibitors with acute major bleeding, sponsored by Portola Pharmaceuticals . Levy:Boehringer Ingelheim: Consultancy; CSL Behring AG: Consultancy; Grifols: Consultancy; Janssen Pharmaceuticals: Consultancy; The Medicines Company: Consultancy. Welsby:NIH: Research Funding; Portola Pharmaceuticals: Research Funding; CSL Behring: Research Funding; Terumo BCT: Research Funding; Zimmer-Biomet: Other: non financial support.

Covert stroke after non-cardiac surgery: a prospective cohort study

BackgroundOvert stroke after non-cardiac surgery has a substantial impact on the duration and quality of life. Covert stroke in the non-surgical setting is much more common than overt stroke and is associated with an increased risk of cognitive decline and dementia. Little is known about covert stroke after non-cardiac, non-carotid artery surgery. MethodsWe undertook a prospective, international cohort study to determine the incidence of covert stroke after non-cardiac, non-carotid artery surgery. Eligible patients were ≥65 yr of age and were admitted to hospital for at least three nights after non-cardiac, non-carotid artery surgery. Patients underwent a brain magnetic resonance study between postoperative days 3 and 10. The main outcome was the incidence of perioperative covert stroke. ResultsWe enrolled a total of 100 patients from six centres in four countries. The incidence of perioperative covert stroke was 10.0% (10/100 patients, 95% confidence interval 5.5–17.4%). Five of the six centres that enrolled patients reported an incident covert stroke, and covert stroke was found in patients undergoing major general (3/27), major orthopaedic (3/41), major urological or gynaecological (3/22), and low-risk surgery (1/12). ConclusionsThis international multicentre study suggests that 1 in 10 patients ≥65 yr of age experiences a perioperative covert stroke. A larger study is required to determine the impact of perioperative covert stroke on patient-important outcomes. Clinical trial registrationNCT01369537.

PWE-225 Choice of enteral feeding tube in the non-surgical oncology setting: Abstract PWE-225 Table 1

Introduction Enteral nutrition (EN) may be indicated in non-surgical oncology patients if they are undernourished or cannot obtain adequate nutritional intake from the oral route alone. 1 The choice of feeding tube depends on several factors including gastro-intestinal (GI) tract accessibility, indication for EN and how long EN is required. Local resources such as access to gastroenterology and interventional radiology may also influence the type of tube inserted. The aim of this service evaluation was to determine the type of enteral feeding tube used in this population and their associated complications. Method We undertook a retrospective review of dietetic records between January 2013 and December 2014 for all patients who required home EN. Data was analysed descriptively. Head and neck and upper GI patients were excluded as this data is collected by separate specialist teams. Results 17 patients were initiated on EN at home during the data collection period. 12 patients had lung cancer, 2 lymphoma, 2 breast cancer and 1 colorectal cancer. Table 1shows the type and duration of feeding tube used. All the 11 patients fed for >30 days started with a NGT. 3 were eventually converted to gastrostomies, 4 were clinically unwell and never stable enough to be considered for a gastrostomy, for 1 patient gastrostomy insertion was contraindicated and 3 patients were predicted to respond sooner to treatment and resume oral intake. 10 (59%) patients experienced complications related to their feeding tube. Of those the most common complications reported were with NGTs. 5 patients (29%) had tubes replaced due to blockage or accidental falling out and 3 patients (18%) had repeated difficulties obtaining aspirates or pH of aspirates Conclusion There was heavy reliance on NGTs as a route of feeding including those requiring feeding for >30 days. It may be more appropriate to consider a gastrostomy insertion for those feeding medium to long term as these are commonly associated with less complications. 2 We encounter repeated problems with blocked NGTs and difficulties with obtaining gastric aspirates. We therefore need to review our practices in terms of information, training and ongoing support provided to patients in order to reduce these types of complications. Disclosure of interest None Declared. References Arends J, et al . ESPEN Guidelines on Enteral Nutrition: Non surgical oncology. Clin Nutr. 2006;25:245–259. Gomes J, et al . Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. The Cochrane Library, Issue 11, 2011.