Perioperative Medical Management Research Articles

Management of Primary Aggressive Tumors of the Knee.

Primary bone sarcomas and aggressive benign bone tumors are relatively rare. It is essential to recognize features that are concerning for these aggressive tumors based on a patient's history, physical exam, and radiographs. Physicians and other health care providers should have a high suspicion for these tumors and promptly refer these patients to orthopaedic oncologists. A multidisciplinary, team-based approach is required to obtain an accurate diagnosis and provide comprehensive care. This review discussed the appropriate work-up, biopsy principles, relevant peri-operative medical management, and surgical treatment options for patients with aggressive primary bone tumors around the knee. Primary bone sarcomas (osteosarcoma and chondrosarcoma) and aggressive benign bone tumors (giant cell tumor, chondroblastoma, and chondromyxoid fibroma) that have a predilection to the distal femur and proximal tibia are the focus of this review.

Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines.

Purpose:Recent survey studies have demonstrated wide variability in practice patterns regarding the management of antithrombotic medications in oculofacial plastic surgery. Current evidence and consensus guidelines are reviewed to guide perioperative management of antithrombotic medications.Methods:Comprehensive literature review of PubMed database on perioperative use of antithrombotic medication.Results/Conclusions:Perioperative antithrombotic management is largely guided by retrospective studies, consensus recommendations, and trials in other surgical fields due to the limited number of studies in oculoplastic surgery. This review summarizes evidence-based recommendations from related medical specialties and provides context for surgeons to tailor antithrombotic medication management based on patient’s individual risk. The decision to continue or cease antithrombotic medications prior to surgery requires a careful understanding of risk: risk of intraoperative or postoperative bleeding versus risk of a perioperative thromboembolic event. Cessation and resumption of antithrombotic medications after surgery should always be individualized based on the patient’s thrombotic risk, surgical and postoperative risk of bleeding, and the particular drugs involved, in conjunction with the prescribing doctors. In general, we recommend that high thromboembolic risk patients undergoing high bleeding risk procedures (orbital or lacrimal surgery) may stop antiplatelet agents, direct oral anticoagulants, and warfarin including bridging warfarin with low-molecular weight heparin. Low-risk patients, regardless of type of procedure performed, may stop all agents. Decision on perioperative management of antithrombotic medications should be made in conjunction with patient’s internist, cardiologist, hematologist, or other involved physicians which may limit the role of guidelines depending on patient risk and should be used on a case-by-case basis. Further studies are needed to provide oculofacial-specific evidence-based guidelines.

Effects of Ketamine, S-Ketamine and MK 801 on Integrin Beta-3-mediated Cell Migration in Pancreatic Carcinoma.

Pancreatic ductal adenocarcinoma is one of the most aggressive malignancies in humans. The main reason for its unfavourable prognosis is the combination of rapid tumour growth, early-onset metastasis and currently still inadequate diagnostic and therapeutic options. Thus, only very few patients are eligible for radical resection of the primary tumour as the only curative treatment option available so far. In the perioperative period, tumour progression and metastasis are facilitated by the activation of key signalling pathways and the altered regulation of transcription factors. Various tumour entities have shown increased expression of the integrin-3 receptor subunit, which correlates with more rapid tumour progression and metastasis through advanced migration, invasion and proliferation. The influence of perioperative medication and postoperative pain management remains unclear. To investigate the effects of ketamine, s-ketamine and MK 801 on integrin beta-3-mediated cell migration in pancreatic cancer cells in vitro. The effects of ketamine, s-ketamine and MK 801 on integrin beta-3 expression were investigated with immunoblot. Cell migratory potentials were analysed using a Cell Migration Assay Kit with a Boyden chamber, in which cells migrate through a semipermeable membrane under different stimuli. Stimulation with ketamine and MK 801 significantly promoted migration in pancreatic cancer cells, increasing the expression of integrin beta-3. Novel therapeutic approaches target the effective modulation of specific signalling and transcription pathways. The prerequisite for such 'target therapies' is comprehensive knowledge about the respective carcinogenesis. Further studies are required to identify the underlying disease mechanisms of pancreatic carcinoma.

Cause-Specific Mortality as a Sequalae of Perioperative Stroke Following Cardiac and Vascular Surgery.

There is a paucity of data regarding cause-specific mortality following a perioperative stroke. In this study, we aim to establish the risk of cause-specific mortality associated with perioperative stroke following cardiac and vascular procedures at 30 days, 90 days, and 1-year postoperative. It is hoped that this fund of knowledge will enhance perioperative risk stratification and medical management for patients who have suffered a perioperative stroke. This is a retrospective cohort study evaluating 277,654 cardiac and vascular surgical patients dually documented within the Inpatient Discharge Claims Database and the Pennsylvania Department of Health Death Statistics database. A univariate assessment followed by a multivariate logistic regression analysis was used to determine the odds of cerebrovascular, cardiovascular, pulmonary, malignancy, infectious, and dementia causes of mortality following perioperative stroke. Perioperative stroke significantly increased the odds of overall mortality (P<0.0001) as well as cause-specific mortality in all categories (P<0.05) except dementia (P=0.8907) at all-time endpoints. Cerebrovascular-related mortality was most impacted by perioperative stroke [adjusted odds ratio: 34.5 (29.1, 40.9), P<0.0001 at 30 d]. Perioperative stroke in the cardiac and vascular surgical population is associated with increased odds of overall, cerebrovascular, cardiovascular, pulmonary, malignancy, and infectious causes of mortality at 30 days, 90 days, and 1-year postoperatively when compared with patients who did not experience a perioperative stroke.

Perioperative Management of Immunosuppressive Medications in Rheumatic Disease Patients Undergoing Arthroscopy.

This manuscript reviews relevant prior literature regarding management of immunosuppressants in patients with rheumatic diseases around the time of orthopedic surgery, highlighting important considerations specifically regarding arthroscopy. Utilization rates of arthroscopic surgery in patients with rheumatic diseases are on the rise, as immunosuppressive treatment options enable them to lead more active lives and hence experience more injuries. Physicians regularly manage patients' glucocorticoids and conventional synthetic and biologic disease modifying antirheumatic drugs around the time of orthopedic surgery, aiming to minimize infection risk while optimizing disease control. However, there is a paucity of randomized controlled trial data for orthopedic surgery-and specifically nothing in the literature pertaining to arthroscopic surgery. Recent guidelines for rheumatic disease patients undergoing elective total hip and knee arthroplasty recommend that most immunosuppressive medications should be held perioperatively, citing the high-risk profile of arthroplasty cases and arthroplasty patients. While 2017 societal guidelines for perioperative immunosuppression during arthroplasty currently serve as a guide for physicians, they may not be applicable to arthroscopy. The less aggressive arthroscopic surgeries span a broader range of patient ages and risk profiles, indications for surgery, and procedural complexity and associated risks. Given these considerations, the majority of routine arthroscopic patients may not require holding of their immunosuppressive medications in the perioperative period.

Primary and Revision Total Knee Arthroplasty in Patients With Pulmonary Hypertension: High Perioperative Mortality and Complications

Although perioperative medical management during total knee arthroplasty (TKA) has improved, there is limited literature characterizing outcomes of patients with pulmonary hypertension (HTN). This study examined mortality, medical complications, implant survivorship, and clinical outcomes in this medically complex cohort. We identified 887 patients with pulmonary HTN who underwent 881 primary TKAs and 228 revision TKAs from 2000 to 2016 at a tertiary care center. Patients were followed up at regular intervals until death, revision surgery, or last clinical follow-up. Perioperative medical complications were individually reviewed. The risk of death was examined by calculating standardized mortality ratios and Cox proportional hazards regression models. Cumulative incidence analysis was used for reporting mortality, revision, and reoperation with death as a competing risk. The 90-day mortality was 0.7% and 4.8% for primary and revision TKAs, respectively. The risk of death was 2-fold higher compared to primary (hazard ratio 2.54, 95% confidence interval [CI] 2.12-3.05) and revision (hazard ratio 2.16, 95% CI 1.78-2.62) TKA patients without pulmonary HTN. Rate of medical complications within 90 days from surgery was 6.5% and 14% in primary and revision TKAs. The 10-year cumulative incidence of any revision was 5% and 16% in primaries and revisions, respectively. Patients with pulmonary HTN undergoing primary and revision TKAs had excess risk of death and experience a high rate of medical complications within 90 days of surgery. Counseling of risks, medical optimization, and referral to tertiary centers should be considered. Level IV.

Narrative Review of Antiplatelet and Anticoagulant Medications for Venous Thromboembolism Prevention in Spine Surgery.

This was a narrative review. The objective of this study was to identify commonly utilized venous thromboembolism (VTE) prophylactic measures, spine surgeon perspective, and provide pharmacologic recommendations from the literature. Considered a preventable cause of morbidity and mortality, VTE remains an important iatrogenic diagnosis of concern. Reported rates of VTE following spine surgery vary widely (0.3%-31.0%). A MEDLINE query identified literature reporting on VTE prevention and outcomes in the setting of spine surgery. Findings extracted from the included articles were summarized in a narrative review format to identify salient aspects of the current literature. Sixty articles were summarized. Many anticoagulation medications that are described in the literature target factors involved in the coagulation cascade common pathway including aspirin and other antiplatelet medications, heparins, and warfarin. Newer direct inhibitors of thrombin and factor Xa are now being utilized for VTE prevention, although with limited use specifically in spine surgery. Perioperative management of antiplatelet and anticoagulation medications in spine surgery requires evidence-based protocols that can account for patient comorbidities and surgery-specific features. Future studies should prospectively focus on establishing stronger recommendations based on pathology, surgical indications, patient comorbidities, region of the spine, and broad surgical intervention to enable effective prophylaxis for VTE. Level II.

Interprofessional learning about medication safety.

Safe medication management requires collaboration between health professionals. A mixed academic and clinician team co-designed and co-facilitated a 2-h interprofessional medication safety workshop, covering medication history taking, perioperative medication management, discharge planning, incident review and dosing and administration calculations. Three workshop sessions were delivered across three sites during September 2019 at a large metropolitan healthcare network. Senior nursing, medical and pharmacy students were invited to participate in the workshops and evaluation. We evaluated satisfaction, learning experience and perceived clinical application for medical, pharmacy and nursing students. Surveys were conducted immediately after each workshop and at 4 weeks. Quantitative data was analysed descriptively and qualitative data analysed using thematic analysis. Forty-five students participated in the evaluative component of the workshops. Mean student response scores demonstrated a high level of satisfaction with the workshop's relevance and utility to their learning. Students expressed strong agreement that the workshop promoted communication across professions for medication safety. Analysis of the qualitative data identified seven key themes, with consistently positive responses provided in each: interactions within the interprofessional team; recognising the importance of teams; learning the process of medication use; acknowledging and working with difference; role playing; thinking patient safety; and authenticity. A 2-h interprofessional workshop about medication safety provided positive learning experiences with high satisfaction to medical, nursing and pharmacy students, and had strong perceived applicability to their future clinical practice.

Chinese expert consensus on keratoprosthesis procedure (2021)

An artificial corneal transplant (keratoprosthesis, KPro) is the only procedure to restore sight for patients with end-stage corneal blindness after multiple failed corneal transplants, severe eye burns, autoimmune-related and cicatricial keratoconjunctival diseases. At present, the representative KPros are Boston KPros and Russian MICOF KPros. They have been used for patients worldwide for nearly 30 years, and the success rate in two years after surgery reaches up to 85%. With the approval of the collar button design KPro (Boston Ⅰ-like artificial cornea) for marketing and the completion of clinical trials of the Miok KPro (MICOF-like artificial cornea) in China, domestic artificial corneas will bring Chinese patients with end-stage corneal blindness opportunities for recovery of eyesight. There are many differences between the KPro procedure and conventional corneal transplantation. In order to standardize the use of domestic KPros in clinical practice and reduce perioperative complications, the Cornea Group of Ophthalmoloy Branch of Chinese Medical Association convened meetings of experts with extensive experience in this field, and a consensus has been reached on the surgical indications, operating specifications, perioperative medication and complication management targeting domestic KPro procedure to guide the performance of artificial corneal transplantation in China. (Chin J Ophthalmol, 2021, 57: 727-733).

Perioperative Satisfaction and Health Economic Questionnaires in Patients Undergoing an Elective Hip and Knee Arthroplasty: A Prospective Observational Cohort Study.

Background:Early hospital discharge shifts the recovery burden toward the patient and can leave patients and their caregivers anxious about the recovery process. Postoperative home care must be broadened to include appropriate and adequate support to address recovery at home. In this prospective study, patient and caregiver perspectives on the level of preparation/satisfaction and cost associated with management of recovery in the postoperative period were evaluated.Methods:We designed this prospective study to measure patient-reported outcomes and to inform the design of a postoperative home monitoring system. Patients undergoing inpatient total hip or knee replacements were recruited from a preadmission clinic at a university hospital. Patients and caregivers completed preoperative, postoperative, and health economic questionnaires. Bivariate analyses were conducted to understand factors associated with satisfaction with care.Results:Of 239 patients and caregivers recruited, preoperative questionnaire was completed by 98.8% of patients, the postoperative follow-up questionnaire was completed by 94.2% of patients, 75% of informal caregivers completed the postoperative follow-up questionnaires, and 93.7% completed the health economic questionnaire. The postoperative satisfaction scores were higher than the preoperative needs/expectation scores for both the overall and individual subscales. Patients undergoing hip arthroplasty reported higher satisfaction scores for postoperative pain management than patients undergoing knee arthroplasty (hip arthroplasty vs. knee arthroplasty: 4.07 ± 1.11 vs. 3.37 ± 1.51; P < 0.001). Patients who underwent knee arthroplasty reported better satisfaction scores with regard to having enough information on how to manage leg stiffness at home compared to patients undergoing hip arthroplasty (knee arthroplasty vs. hip arthroplasty: 3.13 ± 1.35 vs. 2.78 ± 1.30; P = 0.04).Conclusion:Overall, patients are generally satisfied with perioperative care, but they have distinct needs and expectations regarding perioperative medication and postoperative pain management. Virtual postoperative monitoring may be a useful tool during postoperative care to address many of patients’ concerns.

Clinical Characteristics and Magnetic Resonance Imaging–Based Prediction of the KLF4K409Q Mutation in Meningioma

Meningioma is the most common primary brain tumor in adults. In recent years, several non-neurofibromin 2 mutations, i.e., AKT1, SMO, TRAF7, and KLF4 mutations, specific for meningioma have been identified. This study aims to analyze the clinical impact and imaging characteristics of the KLF4K409Q mutation in meningioma.Clinical, neuropathologic, and imaging data of 170 patients who underwent meningioma resection between 2013 and 2018 were retrospectively collected and tumors were analyzed for the presence of the KLF4K409Q mutation. We collected imaging characteristics, performed volumetric analysis of tumor size and peritumoral edema (PTBE), and calculated the edema index (EI, i.e., ratio of PTBE to tumor volume). Receiver operating characteristic curve analysis was performed to identify cut-off EI values to predict the mutational status of KLF4.Eighteen (10.6%) of the meningiomas carried the KLF4K409Q mutation; these were significantly associated with a secretory subtype (P < 0.001) and sphenoid wing location (P = 0.029). Smaller tumor size (P = 0.007), an increased PTBE (P = 0.012), and an increased EI (P = 0.001) proved to be significantly associated with the KLF4K409Q mutation. In receiver operating characteristic curve analysis, EI predicted the KLF4K409Q mutation with an area under the curve of 0.728 (P = 0.0016).The KLF4K409Q mutation is associated with a distinct small tumor subtype, prone to substantial PTBE. EI is a reliable parameter to predict the KLF4K409Q mutation in meningioma, thus providing a tool for improvement of pre- and perioperative medical management.

The Nuts and Bolts of a Successful Non-Narcotic Perioperative Enhanced Recovery After Surgery Protocol.

Enhanced recovery after surgery (ERAS) protocols are widely utilized approaches to perioperative care that advocate preoperative counseling, multimodal perioperative medication management, and early postoperative mobilization to improve post-surgical patient outcomes and satisfaction. The authors aimed to elucidate the mechanism by which each medication utilized in the senior author's ERAS protocol acts, determine the efficacy of this protocol in postoperative pain management, and reveal other factors that may play a role in patients' degree of postoperative pain. A literature review was performed on the medications utilized in the senior author's ERAS protocol. Evidence from the author's previous study on the efficacy of this regimen and anecdotal evidence regarding the psychological component of pain was also compiled. There is evidence that an ERAS protocol is as effective if not more effective than regimens involving opioid medications in management of postoperative pain. These medications act synergistically to block perception of pain by multiple pathways, while minimizing adverse effects that may be associated with high doses of a single medication and are affordable for both the patient and the surgeon. ERAS protocols effectively manage postoperative pain while avoiding the adverse effects associated with opioid medications. Although an emphasis has often been placed on the medications involved in various protocols and avoidance of opioid medications, appropriate counseling on patients' expectations concerning postoperative "pain" or discomfort and a systemic shift in the approach to perioperative pain are perhaps the most important components to holistic non-narcotic postoperative care.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review.

Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery. For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld. Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug. For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing. In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

The Charlson and Elixhauser Scores Outperform the American Society of Anesthesiologists Score in Assessing 1-year Mortality Risk After Hip Fracture Surgery.

Risk adjustment has implications across orthopaedics, including informing clinical care, improving payment models, and enabling observational orthopaedic research. Although comorbidity indices (such as the American Society of Anesthesiologists [ASA] classification, Charlson comorbidity index [CCI], and Elixhauser comorbidity index [ECI]) have been examined extensively in the immediate perioperative period, there is a dearth of data on their three-way comparative effectiveness and long-term performance. Moreover, the discriminative ability of the CCI and ECI after orthopaedic surgery has not been validated in the ICD-10 era, despite new diagnosis codes from which they are calculated. Which comorbidity index (ASA, CCI, or ECI) is associated with the greatest accuracy on receiver operating curve (ROC) analysis with respect to the endpoint of death at 90 days and 1 year after hip fracture surgery in the ICD-10 era? A retrospective study was conducted on all patients undergoing surgical fixation of primary hip fractures at two Level I trauma centers and three community hospitals from October 2016 to May 2019. This time frame allowed for a 1-year baseline period of ICD-10 data to assess comorbidities and at least a 1-year follow-up period to assess mortality. Initially 1516 patients were identified using Common Procedural Terminology and ICD codes, of whom 4% (60 of 1516) were excluded after manual review; namely, those with pathologic fractures (n = 38), periprosthetic fractures (n = 12), and age younger than 18 years (n = 10). Of the patients who were studied, 69% (998 of 1456) were women and the mean ± SD age was 77 ± 14 years; 45% (656 of 1456) were treated with intramedullary nails, 32% (464 of 1456) underwent hemiarthroplasties, 10% (149 of 1456) underwent THAs, 7% (104 of 1456) underwent percutaneous fixations, and 6% (83 of 1456) were treated with plates and screws. The mean ± SD ASA score was 2.8 ± 0.6, CCI was 3.1 ± 3.2, and ECI was 5.2 ± 3.5. Hip fracture fixation was chosen as the operation of interest given the high incidence of this injury, the well-documented effects of comorbidities on complications, and the critical importance of risk stratification and perioperative medical management for these patients. Demographics, comorbidities, surgical details, as well as 90-day and 1-year mortality were collected. Logistic regressions with ROC curves were used to determine the accuracy and comparative effectiveness of the three measures. The 90-day mortality rate was 7.4%, and the 1-year mortality rate was 15.0%. The accuracy (area under the curve [AUC]) for 1-year mortality was 0.685 (95% CI 0.656 to 0.714) for the ASA, 0.755 (95% CI 0.722 to 0.788) for the ECI, and 0.769 (95% CI 0.739 to 0.800) for the CCI. The CCI and ECI were more accurate than ASA (p < 0.001 for both), while the CCI and ECI did not differ (p = 0.30). The ECI (AUC 0.756 [95% CI 0.712 to 0.800]) was more accurate for 90-day mortality than the ASA (AUC 0.703 [95% CI 0.663 to 0.744]; p = 0.04), while CCI (AUC 0.742 [95% CI 0.698 to 0.785]) with ASA (p = 0.17) and CCI with ECI (p = 0.46) did not differ at 90 days. Performance measures and research results may vary depending on what comorbidity index is used. We found that the CCI and ECI were more accurate than the ASA score for 1-year mortality after hip fracture surgery. Moreover, these data validate that the CCI and ECI can perform reliably in the ICD-10 era. If other studies from additional practice settings confirm these findings, as would be expected because of the objective nature of these indices, the CCI or ECI may be a useful preoperative measure for surgeons to assess 1-year mortality for hip fracture patients and should likely be used for institutional orthopaedic research involving outcomes 90 days and beyond. Level III, diagnostic study.

Perioperative Management of Antithrombotic Medications: An Investigation into Current U. S. Ophthalmologic Recommendations.

Purpose:To investigate the availability and content of educational statements or recommendations disseminated by U. S. ophthalmologic organizations regarding perioperative management of antithrombotic agents for ophthalmic and orbital surgery, given the highly variable management of these agents by U. S. ophthalmologists and limited consensus recommendations in the literature.Methods:National U. S. ophthalmic surgical organization websites were systematically examined for educational statements, which were reviewed for discussion of perioperative management of antithrombotic agents including antiplatelet and anticoagulant medications. A “statement” was defined as either: (a) a guideline directed toward ophthalmologists or (b) a surgical/clinical educational posting directed toward ophthalmologists or patients.Results:Fourteen surgical organizations were identified, with eight of these publishing clinical/surgical educational statements. A total of 3408 organizational statements were identified, with 252 (7.4%) and 3156 (92.6%) statements directed toward physicians and patients, respectively. In total, 0.3% (9/3408) of statements discussed perioperative management of antithrombotics. These accounted for 0.8% (2/252) of ophthalmologist-directed statements and 0.2% (7/3156) of patient-directed statements. The majority of patient-directed statements (57.1%, 4/7) recommended that patients discuss antithrombotic cessation with their ophthalmologists, though ophthalmologist-directed information regarding these medications was scant or absent.Conclusions:Educational material from U. S. ophthalmologic organizations regarding perioperative management of antithrombotics is notably lacking despite the fact that ophthalmic and orbital surgeries carry unique vision-threatening hemorrhagic risks. Given these risks, as well as the medicolegal consequences of hemorrhagic complications in ophthalmic surgery, increased dissemination of educational material, and consensus statements by ophthalmic surgical organizations on the perioperative management of antithrombotics may be justified.

The Association of On-Admission Blood Hemoglobin, C-Reactive Protein, and Serum Creatinine With 2-Year Mortality of Patients With Femoral Neck Fractures

IntroductionThe mortality of femoral neck fracture (FNF) is high and every effort should be made to identify and manage any possible risk factors. The aim of this study was to evaluate whether on-admission hemoglobin (Hb) level, C-reactive protein (CRP), and serum creatinine were associated with 2-year mortality after FNF.Patients and MethodsIn this retrospective observational cohort study, we considered for inclusion all displaced FNF patients 65 years and above treated with hemi-arthroplasty between February 2011 and May 2015. We documented the age, sex, cognitive status, and American Society of Anesthesiologists (ASA) classification. The Hb level, CRP, and serum creatinine were measured. The medical records were followed up for 2 years. We fitted different crude and adjusted Cox proportional hazards models to examine whether Hb level <100 g/L, CRP >20 mg/L, and serum creatinine >100 μmol/L were associated with the 2-year mortality, adjusted for age, sex, and ASA class.ResultsA total of 290 patients [208 females (72%), mean age 84 years] were included in the study. More than 50% of patients had impaired cognition and ASA class 3–4. Of the 290 patients, 38.3% (n = 111) had died within 2 years after surgery. Mortality among males was 46.3% (n = 38) while mortality among females was 35,1% (n = 73), p = 0.07. We found that on-admission Hb level <100 g/L was associated with 2-year mortality (HR = 3.3, 95% CI: 1.3–8.3, p < 0.01) while CRP >20 mg/L and serum creatinine >100 μmol/L were not associated with 2-year mortality (p = 0.89 and p = 0.31, respectively).ConclusionOn-admission Hb level <100 g/L, but not CRP >20 mg/L and serum creatinine >100 μmol/L, was associated with 2-year mortality. These results can help healthcare providers identify high-risk FNF patients who probably would benefit from optimized perioperative medical management.

Unexpected upper limb compartment syndrome due to venous thrombosis in frontal glioma surgery: A case report

Although it is well known that 49% cases of upper limb deep-vein thrombosis are due to malignancies and the likelihood of venous thromboembolism is increased in patients with high grade gliomas due to the heightened prothrombotic milieu, requisite preoperative laboratory coagulation studies are not performed routinely in these patients to decide whether appropriate antithrombotic medications are required preoperatively. In addition, it is controversial whether antithrombotic therapy should be initiated before neurosurgery in view of the risk of intraoperative bleeding. Here, we have described the case of a 29-year-old female with high grade frontal malignant astrocytoma who developed the extremely rare complication of upper limb compartment syndrome postoperatively. The patient had no history of thrombotic events, and her basic laboratory parameters were not deranged in the pre-operative period. This rare case, supported with a literature review, suggested that the risk of thrombosis is increased in high grade and large gliomas, making us rethink the overall battery of investigations and perioperative medical management of such cases. We strongly recommend peri-operative coagulation studies and appropriate antithrombotic measures along with vigilant perioperative monitoring to avoid thrombotic complication in this subset of patients.

Management of Priapism in Sickle Cell Patients: Experience of the Urology Department of the University Hospital Centre of Libreville

Introduction: Priapism is a rare pathology, known since antiquity. Sickle cell disease is the main aetiology in Africa. The aim of our work was to report our experience in its treatment. Material and Methods: This is a prospective, descriptive study carried out at the urology department of the Libreville University Hospital from January 2018 to December 2020. All sickle cell patients admitted to urology for priapism were included. The parameters studied were socio-demographic, clinical and therapeutic parameters as well as the evolution after treatment. Result: We collected 19 priapisms in sickle cell patients. The average age was 20.9 years with extremes of 4 and 53 years. Fifteen patients were homozygous SS. All patients had stasis priapism. The average consultation time was 22.4 hours. All patients had perioperative medical management combining hyperhydration, analgesia and antibiotic prophylaxis. A vasoactive drug was administered to 13 patients. Sixteen patients had a puncture of the corpus cavernosum. A distal cavernosal-spongiosum shunt under penile block was performed in 6 patients. The outcome was favorable from the outset in 12 cases, marked by complete detumescence of the corpus cavernosum. Partial detumescence was noted in 7 patients with the need for a new puncture of the cavernous body. A complication such as edema of the penis was in only one of our patients. A recurrence was noted in 2 patients. After an average follow-up of 6 months, no sequelae erectile dysfunction was observed. Conclusion: Priapism is a frequent complication among sickle cell patients in Libreville. Medical management associated with a cavernous puncture with administration of vasoactive drugs allows a favourable evolution without after-effects.

Anxiety and Depression Impact on Inhospital Complications and Outcomes After Total Knee and Hip Arthroplasty: A Propensity Score-Weighted Retrospective Analysis.

The purpose of this study was to assess the impact of anxiety and depression on immediate inhospital outcomes and complications after total joint arthroplasty of the hip (total hip arthroplasty [THA]) and knee (total knee arthroplasty [TKA]) using a large national registry. Data from the National Inpatient Sample was used to identify all patients undergoing TKA and THA between 2006 and 2015. Patients were divided in four groups based on a concomitant diagnosis of depression, anxiety, depression plus anxiety, and neither depression nor anxiety (control group). Propensity score analysis was performed to determine whether these psychiatric comorbidities were risk factors for inhospital economic, disposition, and complication outcomes. A total of 5,901,057 TKAs and 2,838,742 THAs were performed in our study period. The relative percentage of patients with anxiety and depression undergoing these procedures markedly increased over time. All three psychiatric comorbidity groups were markedly associated with an increased risk of postoperative anemia and were markedly associated with other inhospital complications compared with the control group. Notable associations were also found between the study groups and total charges, length of stay, and disposition. Anxiety and depression are major risk factors for inhospital complications and are markedly associated with economic and disposition outcomes after TKA and THA. The relative proportion of patients with anxiety and depression undergoing these procedures is rapidly increasing. It is critical for clinicians to remain aware of these risk factors, and attention should be directed on the development of standardized perioperative optimization protocols and medication management for these patients. Level III, retrospective study.

Medical Perioperative Management In Patient with Acute Kidney Disease

Bartter syndrome is inherited tubulopathy caused by mutations in several genes causing hypokalemia, hypomagnesemia, hypocalcemia with hypercalciuria, and metabolic alkalosis. Beside from inherited disorder, Bartter syndrome can be caused by the use of aminoglycosides, so it is called Bartter-like syndrome. Hypokalemia has been reported as a side effect of aminoglycosides in many studies, but Bartter-like syndrome due to aminoglycosides has only been reported in a few case reports. We report a 43 years old female patient who developed muscle weakness due to hypokalemia. We found the patient’s laboratory results was consistent with Bartter syndrome. The patient had MDR-TB and received combination therapy with capreomycin for two months. We diagnosed a patient with Bartter-like syndrome due to capreomycin. Following diagnosis, we discontinued capreomycin and started potassium, magnesium and calcium therapy. After electrolyte imbalances improved, capreomycin was given three times per week and the patient was no longer experiencing the same condition.