Ventricular-arterial coupling (VAC), defined as the ratio of arterial elastance (Ea) to left ventricular end-systolic elastance (Ees), provides valuable insights for optimizing perioperative hemodynamic management. While transthoracic echocardiography and transesophageal echocardiography (TEE) are used to estimate Ees, both modalities require substantial operator expertise and transthoracic echocardiography may be limited by suboptimal imaging conditions, especially in the perioperative setting. Therefore, the authors propose using carotid ultrasound as a noninvasive and more accessible alternative to estimate VAC. Given its close anatomic and physiological relationship with the proximal aorta, the carotid artery reflects central arterial hemodynamics and may serve as a promising surrogate for VAC. This study aimed to evaluate the agreement between carotid ultrasound and TEE in measuring VAC in patients undergoing cardiac surgery. Prospective observational pilot study. Operating room. Twelve adult patients undergoing elective coronary artery bypass grafting surgery. Ultrasound measurements were obtained both preoperatively and postoperatively using carotid ultrasound and TEE, and the interchangeability between Ea, Ees, and VAC was evaluated with correlation and Bland-Altman analyses. Ea was calculated using the systolic blood pressure and stroke volume, while Ees was estimated using the single-beat method proposed by Chen et al. MEASUREMENTS AND MAIN RESULTS: Strong correlations were observed between carotid ultrasound and TEE measurements for Ea (r = 0.87; 95% confidence interval [CI], 0.73-0.95), Ees (r = 0.82; 95% CI, 0.63-0.92), and VAC (r = 0.79; 95% CI, 0.56-0.90). The estimation of VAC using carotid ultrasound demonstrated clinically acceptable accuracy and precision, with a bias of -0.01 (95% CI, -0.07 to 0.05) and limits of agreement of ±0.30 (range, -0.18 to 0.39). Carotid ultrasound-derived VAC demonstrated good correlation with VAC measured using TEE in this pilot study. These preliminary results suggest that carotid ultrasound may be useful for investigating VAC at the bedside, but further studies with larger sample sizes are needed to validate these findings.

MRI-guided interventional techniques integrate the high-resolution imaging capabilities of magnetic resonance imaging (MRI) with minimally invasive interventional diagnostic and therapeutic technologies. Through real-time dynamic imaging guidance, magnetic compatibility of instruments, and multiparametric functional assessment, these techniques enable precise diagnosis and targeted treatment of lesions throughout the body. Leveraging MRI' s core strengths of high soft-tissue resolution, multiparametric functional imaging, real-time monitoring, and absence of ionizing radiation, MRI-guided interventions offer unique value in complex areas such as the brain and liver dome, where traditional CT or ultrasound guidance may fall short. They are widely applied in diagnostic and therapeutic scenarios, including percutaneous biopsy and tumor ablation treatments such as radiofrequency, microwave, cryotherapy, and focused ultrasound, as well as neuromodulation. However, current clinical applications face challenges such as significant variability in equipment, lack of standardized procedures, and inadequate management of complications, leading to inconsistent therapeutic outcomes and restricted application of the technology. To address these issues, the MRI Interventional Expert Group under the Chinese College of Interventional Physicians, in collaboration with multidisciplinary experts, has developed this consensus statement. It systematically standardizes the indications and contraindications, selection criteria for equipment and instruments, requirements for operating room management, detailed procedural steps, perioperative quality control measures, and prevention and management strategies for various complications. The aim is to provide standardized guidance for clinical practice, enhance the safety and efficacy of diagnosis and treatment, and promote the standardized application of this technology.

Hypertension (HTN) is common in patients presenting for dermatologic surgery and may be a modifiable risk factor for procedural complications, yet standardized dermatology-specific guidelines on blood pressure (BP) management are limited. To synthesize evidence on the impact of HTN on cutaneous surgery and clarify dermatologists' role in BP assessment and management and propose practical clinical guidelines. The authors conducted a literature search, identified studies relevant to HTN management in dermatologic surgery, comparable office-based surgical specialties, and recent American Heart Association perioperative guidelines. Although HTN may increase perioperative complications, rigid BP cutoffs are not supported by current evidence. Rather, a risk-based framework is supported: surgery may proceed with caution until BP exceeds 200/110 mm Hg without symptoms of acute hypertensive end organ damage. For BP above this threshold, clinicians should attempt to lower BP through rest, anxiolytics, or other calming measures. If BP remains uncontrolled, surgery should be deferred and patients referred for primary care provider management. Dermatologists should measure BP at the initial consultation visit, continue home antihypertensives, maintain adequate analgesia, and use 5-mg diazepam as needed for perioperative anxiety. A risk-stratified approach to HTN, combined with adjunct BP management strategies, supports safe and timely dermatologic surgery.

Occipital meningomyeloceles are rare and challenging conditions for the anaesthesiologist, mainly because of the difficulty in securing the airway, the need for special positioning, and the constant risk of rupturing the sac during handling. We report two paediatric cases, a neonate and an infant, both presenting with large occipital meningoencephaloceles requiring individualised airway strategies driven by extreme lesion size and anatomical constraints. In each case, airway access was achieved using modified positioning techniques such as lateral positioning and the head-dangling method to avoid pressure on the swelling. Anaesthetic management was directed at maintaining body temperature, ensuring fluid balance and keeping the circulation stable throughout surgery. Both children underwent successful excision of the lesion and recovered well without neurological complications. These cases highlight the importance of thoughtful preparation, adaptable airway strategies and close teamwork between surgeons and anaesthesiologists in improving outcomes for children born with such complex congenital problems.

BackgroundTotal knee arthroplasty is often complicated by perioperative blood loss. Tourniquets reduce visible bleeding; however, prolonged use may increase hidden blood loss. Intra-articular tranexamic acid may enhance hemostasis without increasing the risk.MethodsWe retrospectively analyzed 85 unilateral primary total knee arthroplasties for osteoarthritis (September 2022 to March 2025). All patients received 1 g intravenous tranexamic acid before incision and were nonrandomly assigned to either of three groups based on evolving institutional protocols and surgeon discretion during the study period as follows: (a) Group A (full-duration tourniquet, n = 28); (b) Group B (half-duration tourniquet, n = 27); and (c) Group C (half-duration tourniquet plus 2 g intra-articular tranexamic acid, n = 30). The primary outcome was postoperative day 3 hemoglobin level; secondary outcomes were calculated blood loss, transfusion, pain scores, early Hospital for Special Surgery knee score (function), and perioperative complications.ResultsA total of eighty-five unilateral primary total knee arthroplasties were analyzed (Group A, n = 28; Group B, n = 27; and Group C, n = 30). Baseline variables were comparable across the three groups. On postoperative day 3, hemoglobin level was highest in Group C (10.97 ± 0.69 g/dL) compared with those in Groups A (9.89 ± 0.80) and B (10.05 ± 0.58) (overall p < 0.001; Groups C vs. A/B, both p < 0.001). Total blood loss decreased stepwise (Group A, 1403 ± 136 mL; Group B, 1163 ± 124 mL; and Group C, 770 ± 121 mL; all pairwise p < 0.001); a similar pattern was observed for hidden blood loss (Group A, 1388 ± 137 mL; Group B, 929 ± 128 mL; and Group C, 529 ± 121 mL; all pairwise p < 0.001). Intraoperative blood loss was lowest in Group A (median 15 mL) compared with those in Groups B (220 mL) and C (230 mL) (p < 0.001). Transfusion rates were 28.6% in Group A, 14.8% in Group B, and 3.3% in Group C (overall p = 0.024). Postoperative pain, as indicated by visual analog scale scores, was lowest in Group C (scores on postoperative days 1 and 3: 4.95 ± 0.85 and 3.57 ± 0.61, respectively) compared with those in Groups B (scores on postoperative days 1 and 3: 6.02 ± 1.22 and 4.63 ± 0.87, respectively) and A (scores on postoperative days 1 and 3: 7.86 ± 0.85 and 6.54 ± 1.00, respectively) (both time points p < 0.001). Based on a comparison of the Hospital Special Surgery knee scores of the three groups, Group C demonstrated superior early functional outcomes (scores: 62.33 ± 2.71 at postoperative 1 week and 83.73 ± 3.14 at postoperative 1 month) compared with Groups B (scores: 56.81 ± 3.11 at postoperative 1 week and 79.11 ± 3.64 at postoperative 1 month) and A (47.86 ± 3.39 at postoperative 1 week and 72.36 ± 3.72 at postoperative 1 month) (all p < 0.01). However, the 6-month Hospital for Special Surgery knee scores of the three groups were comparable (Group A: 89.93 ± 2.42; Group B, 89.96 ± 2.53; and Group C, 91.13 ± 2.06; p = 0.09). Overall complication rates did not differ between the three groups (Group A, 7.1%; Group B, 7.4%; Group C, 3.3%; p = 0.734).ConclusionIn total knee arthroplasty patients, the combination of a half-duration tourniquet with intra-articular tranexamic acid may provide superior perioperative blood management compared with a full-duration tourniquet or half-duration tourniquet alone. This strategy may reduce total and hidden postoperative blood loss, reduce hemoglobin loss, and lower transfusion rates. Additionally, it may reduce postoperative pain and promote earlier recovery of knee function. In addition, this treatment combination did not cause a significant increase in complications, including thrombosis or infection.

Since its introduction in 1974, the artificial urinary sphincter (AUS) has been considered the gold standard for treatment of moderate to severe male stress urinary incontinence. This article provides an overview of perioperative management and long-term outcomes, offering an evidence-based foundation for clinical practice. Current evidence on patient selection, preoperative diagnostics, surgical techniques, long-term outcomes, and management of complications was reviewed, based on recent studies, multicenter cohorts, and registry data. The implantation of an AUS generally results in high continence rates and substantial improvement in quality of life. Perioperative risk factors, including prior radiotherapy, diabetes mellitus, or previous urethral procedures, increase the likelihood of postoperative complications such as infections, urethral erosions, or mechanical failure. Specialized centers with extensive experience achieve better functional outcomes and lower revision rates. Despite potential complications, most patients report sustained satisfaction and an improved quality of life following AUS implantation. The AUS is an effective treatment option for moderate to severe stress urinary incontinence. Perioperative risk assessment, specialized implantation techniques, and treatment in experienced centers are crucial for therapeutic success. Prospective registry and multicenter data provide valuable guidance for evidence-based patient selection, complication management, and of long-term outcome optimization.

Perioperative Biologic Disease-Modifying Antirheumatic Drugs, Risks of Infections, and Wound Complications in Patients With Rheumatoid Arthritis Undergoing Elective Hand Surgery.

Iron Deficiency Anaemia (IDA) is the world’s leading nutritional disorder. While the conventional cardiovascular response to anaemia involves tachycardia due to sympathetic stimulation, anaemia-related autonomic dysfunction may paradoxically present as bradycardia. Such an atypical presentation can complicate perioperative management, particularly in patients scheduled for major surgery. Hereby, the authors present a case of a 54-year-old postmenopausal woman with an ovarian tumour and symptomatic IDA who exhibited autonomic dysfunction manifesting as sinus bradycardia. Her haemoglobin level was 4.7 g/dL, with markedly low ferritin levels consistent with chronic iron deficiency. She was transfused with three units of packed red blood cells, after which her haemoglobin improved to 11.2 g/dL. Combined epidural–general anaesthesia was administered for tumour resection. Intraoperatively, episodes of bradycardia and hypotension occurred but were successfully managed with intravenous glycopyrrolate and fluid boluses. The postoperative course was uneventful, with no recurrence of bradycardia. The present case highlights the importance of recognising anaemia-induced autonomic dysfunction as a potential perioperative complication. Careful anaesthetic planning, preoperative optimisation, vigilant haemodynamic monitoring, and timely intervention can result in favourable outcomes in such challenging situations.

Postoperative pain after video-assisted thoracoscopic surgery affects 43%-99% of patients and is associated with prolonged hospital stay. Pre- and intraoperative risk factors can help identify patients at higher risk of postoperative pain. This study aimed to assess if quantitative sensory testing, psychological factors, and patient characteristics can predict postoperative pain. Patients undergoing elective video-assisted thoracoscopic surgery for confirmed or suspected lung cancer were included. Pain sensitivity was evaluated by quantitative sensory testing using cuff algometry, and psychological factors were assessed by the pain catastrophizing scale, and the hospital anxiety and depression scale. Clinical pain was assessed bidaily and summarized as time-weighted pain and opioid consumption was measured as cumulative dose, both within 48 h of surgery. Prediction models using pre- and intra-operative variables were established, and backward elimination was applied to identify independent predictors. Domain-specific models were constructed within five domains of predictors (i.e., quantitative sensory testing, psychological factors, demographics, perioperative, and tumour pathology). Subsequently, independent variables from the five domain-specific models were combined into a multifactorial model. Domain-specific models explained between 5.1%-12.8% of variance except the demographics model which explained 39.5% of opioid consumption. The multifactorial models for pain intensity and opioid consumption explained 20.3% and 40.4%, respectively. This study suggests that pre- and intra-operative factors contribute to the prediction of postoperative pain intensity and opioid consumption with varying precision. Demographic variables proved to be best and predicted 39.5% of postoperative opioid consumption. The multimodal models explained 20.3% of postoperative pain and 40.4% of postoperative opioid consumption. This assessment and analysis presents factors that are associated with how patients who have undergone video-assisted thoracosopic surgery as a group report post-operative pain. Both patient-specific factors and perioperative management details appear to contribute.

Denosumab is a humanized monoclonal antibody targeting receptor activator of nuclear factor-κB ligand (RANKL) and is commonly used in the treatment of osteoporosis and cancer-related bone metastases. However, the persistent use of denosumab has been associated with an increasing incidence of denosumab-related osteonecrosis of the jaw (DRONJ), particularly following tooth extraction. This expert consensus aims to develop clinical management guidelines for the perioperative period of tooth extraction in patients who are currently receiving or have previously received denosumab therapy. The consensus covers the definition, etiology, epidemiology, staging, and risk factors of DRONJ, focusing on preoperative assessment, risk-based prevention strategies, minimally invasive surgical techniques, and postoperative follow-up protocols. The core management strategy for DRONJ emphasizes individualized decision-making based on a comprehensive preoperative assessment of medication history, local infection, and systemic conditions. The main risk factors for DRONJ include high-dose and long-term denosumab therapy, preexisting oral infections, such as periodontitis and periapical periodontitis, and invasive dental procedures, including tooth extraction, diabetes, and concomitant use of glucocorticoids or antiangiogenic agents. Core preventive measures include strict perioperative oral care, risk assessment-based antibiotic prophylaxis, long-term drug holidays, which were developed by dentists and physicians prio-ritizing the primary disease, and minimally invasive surgical techniques for managing trauma, preserving local blood supply, thoroughly removing infected tissues, and ensuring tight wound closure. This consensus highlights the importance of multidisciplinary collaboration between dental and clinical medicine experts in managing DRONJ. High-quality research is necessary to provide an evidence-based foundation for optimizing DRONJ prevention and treatment strategies.

Postoperative Complications in Patients With Heart Failure With Reduced vs Preserved Ejection Fraction Undergoing Total Hip and Knee Arthroplasty.

Periprosthetic joint infection (PJI) is a devastating complication following lower limb arthroplasty that is associated with major physical, psychological, and social harm, yet its aetiology remains poorly evaluated. The aim of this study was to identify characteristics associated with an increased risk of PJI following primary total hip (THA) or total knee arthroplasty (TKA) performed for arthritis. A retrospective cohort study was conducted using prospectively collected clinical data from a bespoke institutional database, at a single high-volume study centre. THA and TKA cases performed for end-stage arthritis between 1 January 2010 and 31 December 2021 were included. Variables collected included: demographic details, clinical factors, surgical factors, and perioperative management factors. The primary outcome measure was PJI related to the same prosthetic joint from two weeks to 11 years, and was further sub-categorized as superficial or deep infection. A total of 30,102 procedures (15,191 THA and 14,911 TKA) performed in 25,829 patients were included. On adjusted analyses, factors independently associated with an increased risk of deep infection in THA were male sex (OR 1.96 (95% CI 1.18 to 3.26); p = 0.009); perioperative blood transfusion (OR 4.82 (95% CI 1.42 to 16.37); p = 0.012); obesity class II (OR 3.55 (95% CI 1.37 to 9.24); p = 0.009); and obesity class III (OR 3.68 (95% CI 1.16 to 12.88); p = 0.028). Factors independently associated with an increased risk of deep infection in TKA were perioperative blood transfusion (OR 9.74 (95% CI 3.81 to 24.9); p < 0.001) and operating time (OR 1.01 (95% CI 1.00 to 1.02); p = 0.049). The findings highlight the importance of holistic strategies to support personalized weight optimization while awaiting surgery, management of perioperative anaemia, and transfusion minimization strategies.

Impact of Enhanced Recovery After Surgery (ERAS) compliance on the effect and clinical outcomes for ankle fractures: A multicenter retrospective study.

Current status of powered intracapsular tonsillectomy and adenoidectomy: A minimally invasive paradigm for pediatric obstructive sleep apnea surgery.

Davis and colleagues' longitudinal Fremantle Diabetes Study Phase II study makes a pivotal contribution by demonstrating that type 2 diabetes doubles the risk of incident aortic valve replacement (AVR) with distal symmetrical polyneuropathy (DSPN) and intensive glucose-lowering therapy as key associates.1 Its strengths include rigorous age, sex and postcode matching, long-term follow-up from 2008 to 2021, and integration of competing risk models that address critical limitations of prior research and reinforce the clinical relevance of its findings. Several underdeveloped dimensions could further enhance the study's translational value and we aim to elaborate on targeted recommendations to address these aspects. Our core suggestions focus on three interconnected areas to deepen understanding and clinical applicability. First, subgroup stratification is essential as the study aggregates type 2 diabetes participants. Stratifying by diabetes duration, such as less than 5 years, 5–10 years and more than 10 years, would clarify whether AVR risk accumulates linearly or if thresholds exist. Distinguishing between glucose-lowering medication classes, such as sodium-glucose cotransporter 2 inhibitors versus insulin, could reveal if specific therapies modify valvular risk.2 Second, a mechanistic exploration of the DSPN-AVR association is needed beyond the common soil hypothesis.3 Investigating sarcopenia as a mediator, given its links to both DSPN and aortic stenosis progression,4 could identify modifiable targets like resistance training. Third, outcome granularity matters in distinguishing urgent versus elective AVR as the former carries a higher perioperative risk.5 Assessing post-AVR non-mortality outcomes, such as infections and renal dysfunction, would provide a more comprehensive view of the diabetes-related burden and guide perioperative management. These recommendations build on the study's robust foundation without undermining its core findings. By addressing subgroup-specific risk, mechanistic mediators and outcome detail, future research can refine risk stratification, identify targeted interventions and optimize personalized care for adults with type 2 diabetes at risk of severe valvular heart disease. Davis and colleagues' work rightly highlights the need for heightened clinical suspicion of aortic stenosis in older adults with type 2 diabetes, and these extensions will further strengthen its translational impact. Peng Liu and Xiaoyu He: conceptualization, writing—original draft. Zejun Song: conceptualization, writing—review and editing. None. The authors received no specific funding for this work. The authors declare that there are no conflicts of interest.

The Impella family of percutaneous a left ventricular assist devices are increasingly used for hemodynamic support in patients with cardiogenic shock or advanced heart failure. However, guidance on anesthetic management for patients with Impella support undergoing noncardiac procedures remains sparse. This study reviews perioperative practices and outcomes to inform clinical management. Following institutional review board approval, a retrospective analysis was performed of adult patients receiving an Impella device (2.5, CP, 5.0, or 5.5) at Thomas Jefferson University Hospital, Philadelphia, USA, between December 2017 and October 2024. Patients, who subsequently underwent procedures involving anesthesia care were included. Demographics, procedure type, anesthetic technique, pharmacologic management, hemodynamic support, and intraoperative outcomes were analyzed descriptively. Among 165 Impella recipients, 41 underwent anesthesia requiring procedures: Eight gastrointestinal (GI) and 33 non-GI interventions. All GI cases involved Impella 5.5 devices, commonly for urgent endoscopy in gastrointestinal bleeding. General anesthesia was used in 50% of GI and 94% of non-GI cases. Propofol and etomidate were predominant induction agents; fentanyl and rocuronium were widely utilized. Phenylephrine and norepinephrine were the most frequent vasopressors, with adjunctive use of dobutamine or epinephrine. No intraoperative device malfunctions, dislodgements, or arrests occurred. With individualized anesthetic planning and vigilant hemodynamic control, Impella-supported patients can safely undergo diverse procedures. Deep sedation may suffice for select endoscopic interventions, whereas complex non-GI operations generally require general anesthesia. These findings provide a foundation for developing standardized perioperative management protocols for this growing patient population.

Femoral neck fractures (FNF) in older adults are frequently managed with either total hip arthroplasty (THA) or hemiarthroplasty (HA). Despite improvements in surgical techniques, mortality rates after hip fracture surgery remain high. Identifying predictors of early mortality may enhance surgical decision-making, optimize perioperative management, and improve patient outcomes. The purpose of this study was to determine the short- and mid-term mortality rates after THA and HA for FNF, to identify clinical, demographic, and laboratory factors associated with 30-, 90-, and 180-day mortality, and to establish clinically relevant cutoff thresholds for significant continuous variables to stratify risk. We retrospectively reviewed 2379 consecutive patients treated for sub-capital FNF at a tertiary trauma center between [insert study years]. Of these, 831 underwent THA and 1548 underwent HA. Mortality was assessed at 30, 90, and 180 days postoperatively. Demographic, clinical, and laboratory parameters were analyzed using univariate and multivariate logistic regression models. Receiver operating characteristic (ROC) curve analysis was performed to identify optimal cutoff thresholds for significant continuous predictors. Among THA patients, mortality was 1.4% at 30 days, 3.4% at 90 days, and 5.1% at 180 days. Postoperative albumin ≤2.85g/dL predicted 30-day mortality, while C-reactive protein (CRP)>19.15mg/dL was independently associated with mortality at 90 and 180 days. Among HA patients, mortality was 6.6% at 30 days, 12.9% at 90 days, and 17.6% at 180 days. Predictors of 30-day mortality included white blood cell count (WBC)>14.48×109/L, albumin <3.55g/dL, and Charlson Comorbidity Index (CCI)>7.5. At 90 and 180 days, age >83.65 and>89.34 years, WBC >13.49×109/L, albumin <3.35-3.45g/dL, creatinine >1.08mg/dL, and CCI >6.5 were associated with higher mortality risk. This study identified several laboratory and clinical markers that predict short- and mid-term mortality following hip arthroplasty for FNF. Hypoalbuminemia, elevated inflammatory markers, renal dysfunction, and high comorbidity burden were consistent risk factors. Incorporating these parameters into preoperative assessment may improve patient selection, perioperative optimization, and shared decision-making. III.

Prediction of Neurological Functional Recovery after Carotid Endarterectomy Using Machine Learning and Carotid Computed Tomography Angiography Radiomics.

The NEonate and Children audiT of Anesthesia pRactice IN Europe (NECTARINE) study, led by the ESAIC Clinical Trials Network, collected prospective data on 5609 children up to 60 weeks postmenstrual age undergoing 6542 anesthetic procedures across 165 centers in 31 European countries (ESAIC_CTN_NECTARINE). While the study provides comprehensive European data, healthcare systems, perioperative practices, and organizational standards vary considerably between countries. Germany was selected a priori for a dedicated subcohort analysis due to its substantial contribution (10.3% of the total dataset) and notable differences to other European countries in the absence of a centralization and national training program in pediatric anesthesia. This focused evaluation aimed to benchmark national data against European findings, identify country-specific strengths and weaknesses, and support targeted quality improvement and guideline development within the German healthcare system. To compare the incidence, nature, and consequences of perioperative critical events between the German and non-German NECTARINE cohorts and to assess practice-related risk factors and outcomes. Data from 14 German centers were analyzed using mixed-effects logistic regression to examine associations between critical events and 30-day morbidity and mortality. Perioperative management practices and risk profiles were compared with those from the rest of the European cohort. The German cohort showed a significantly higher rate of critical events (47.0% vs. 33.9%, p < 0.001), with cardiovascular instability being most frequent (82.6%). Within German centers, the occurrence of a critical event nearly tripled the risk of postoperative complications within 30 days (OR: 2.85; 95% CI: 1.67-4.87). ASA status and number of surgeries were also significant predictors of morbidity. This prospectively defined subanalysis demonstrates that perioperative outcomes and practice patterns in Germany differ from European averages, particularly regarding the frequency of critical events, thresholds for intervention, staffing ratios, and complication profiles. These insights highlight the need for targeted interventions in German pediatric anesthesia, contribute to contextualizing European data, and offer baseline data for future cross-border quality initiatives and trials. ClinicalTrails.gov NCT02350348.

Targeting leukocytes, neutrophil extracellular traps and cytokines: A conceptual review to prevent primary graft dysfunction after lung transplantation.