Preoperative Clinical Variables Research Articles

Machine learning−derived multivariable predictors of postcardiotomy cardiogenic shock in high-risk cardiac surgery patients

ObjectiveTo develop a model for preoperatively predicting postcardiotomy cardiogenic shock (PCCS) in patients with poor left ventricular (LV) function undergoing cardiac surgery. MethodsFrom the Society of Thoracic Surgeons Adult Cardiac Database, 11,493 patients with LV ejection fraction ≤35% underwent isolated on-pump surgery from 2018 through 2019, of whom 3428 experienced PCCS. In total, 68 preoperative clinical variables were considered in machine-learning algorithms trained and optimized using scikit-learn software. ResultsCompared with patients with ideal recovery, those that did were younger (65 vs 67 years), more likely female, Black, with low LV ejection fraction (26.5 vs 28.9%), previous myocardial infarction, chronic lung disease, diabetes, reoperation, or advanced heart failure. Among those with PCCS versus ideal recovery, operative mortality was 27% (925/3428) versus 0.1% (5/8065). PCCS occurred more often after coronary artery bypass grafting with concomitant mitral valve repair or after longer perfusion and clamp times. Reliable preoperative PCCS predictors were more advanced cardiac, liver, and renal failure; frailty; and greater white cell count. Out of sample test set receiver operating curve achieved an area under the curve of 0.74 with acceptable calibration Hosmer-Lemeshow statistic χ2 = 1.33, P = .25. ConclusionsIn patients with severe LV dysfunction undergoing cardiac surgery, risk of PCCS is elevated by preoperative failure of other organ systems and complexity of the planned operation that prolongs myocardial ischemia and cardiopulmonary bypass. This risk calculator could serve as an important tool to preoperatively identify patients in need of advanced levels of support.

Survival evaluation of surgical extrusion for the management of complicated crown-root fractured maxillary incisors: A clinical study.

This study aimed to clinically evaluate the survivability of surgically extruded teeth, to assess the success rate and predictable factors pertaining to alterations in both hard and soft tissues adjacent to extruded teeth. A total of 46 complicated crown-root fractured maxillary central and lateral incisors with >75% tooth structure loss relatively due to trauma were included. Preoperative clinical and radiographic variables were recorded. Single operator performed endodontic treatment before surgical extrusion. Patients were recalled for review at 6, 12, 18, 24 and 36 months. Survivability was assessed using Kaplan-Meier survival analysis. With a mean follow-up of 2.8 years, survival rate was 95.7%. Mobility observed in only two cases. The crown-root ratio was favourable (1:2) in all the cases except for five teeth. Only two teeth displayed non-progressive root resorption. Survival of surgically extruded teeth relies on significant predictors like favourability of CRR and implementation of atraumatic extrusion.

Presentation and outcomes of women and men undergoing surgery for degenerative mitral regurgitation.

Degenerative mitral regurgitation is associated with heart failure, arrhythmia and mortality. The impact of sex on timing of surgical referral and outcomes has not been reported comprehensively. We examined preoperative status and surgical outcomes of male versus female degenerative mitral valve regurgitation patients undergoing surgery. We reviewed our institutional database for all patients undergoing surgery for degenerative mitral regurgitation between 2013 and 2021. Preoperative clinical and echocardiographic variables, surgical characteristics and outcomes were compared, and left atrial strain in available images. Of 963 patients, 314 (32.6%) were female. Women were older (67 vs 64 years, P = 0.031) and more often had bileaflet prolapse (19.4% vs 13.8%, P = 0.028), mitral annular calcification (12.1% vs 5.4%, P < 0.001) and tricuspid regurgitation (TR; 31.8% vs 22.5%, P = 0.001). Indexed left ventricular end-diastolic and end-systolic diameters were higher in women, with 29.4 vs 26.7 mm/m2 (P < 0.001) and 18.2 vs 17 mm/m2 (P < 0.001), respectively, and left atrial conduit strain lower (17.6% vs, 21.2%, P = 0.001). Predicted risk of mortality was 0.73% vs 0.54% in men (P = 0.023). Women required mechanical circulatory support more frequently (1.3% vs 0%, P = 0.011), had longer intensive care unit stay (29 vs 26 h, P < 0.001), mechanical ventilation (5.4 vs 5 h, P = 0.036), and overall hospitalization (7 vs 6 days, P < 0.001). There was no difference in long-term reoperation-free survival (P = 0.35). Women undergoing mitral valve repair are older and show indicators of more advanced disease with long-standing left ventricular impairment. Guidelines may need to be adjusted and address this disparity, to improve postoperative recovery times and outcomes.

Risk prediction of multiple-station N2 metastasis in patients with upfront surgery for clinical single-station N2 non-small cell lung cancer

To investigate long-term outcomes and develop a risk model for pathological multi–station N2 (pN2b) in patients who underwent upfront surgery for clinical single–station N2 (cN2a) non–small cell lung cancer (NSCLC). From 2006 to 2018, 547 patients who had upfront surgery for suspected cN2a NSCLC underwent analysis. A risk model for predicting pN2b metastasis was developed using preoperative clinical variables via multivariable logistic analysis. Among 547 clinical cN2a NSCLC patients, 118 (21.6%), 58 (10.6%), and 371 (67.8%) had pN0, pN1, and pN2. Among 371 pN2 NSCLC patients, 77 (20.8%), 165 (44.5%), and 129 (34.7%) had pN2a1, pN2a2, and pN2b. The 5-year overall survival rates for pN2a1 and pN2a2 were significantly higher than for pN2b (p = 0.041). Histologic type (p < 0.001), age ≤ 50 years (p < 0.001), preoperatively confirmed N2 metastasis (p < 0.001), and clinical stage IIIB (vs. IIIA) (p = 0.003) were independent risk factors for pN2b metastasis. The risk scoring system based on this model demonstrated good discriminant ability for pN2b disease (area under receiver operating characteristic: 0.779). In cN2a NSCLC patients, those with multiple N2 metastases indicate worse prognosis than those with a single N2 metastasis. Our risk scoring system effectively predicts pN2b in these patients.

Endodontic characteristics of mandibular premolar with dens evaginatus: a retrospective study.

This study aimed to investigate the endodontic characteristics of mandibular premolars with dens evaginatus (DE) that require endodontic treatment. Patients who underwent endodontic treatment were enrolled. The inclusion criteria were patients who underwent root canal treatment in the lower permanent teeth with DE and were followed up for at least 1 year. Preoperative clinical and radiographic variables were obtained. The frequency distribution of the preoperative variables was compared using the χ2 or Fisher's exact tests. The significance of the change in periapical health index (PAI) and root development stages before and after treatment was examined using the Wilcoxon signed-rank test. A total of 150 teeth of 134 patients with an average age of 15.3 years were included. The percentage distribution comparison of the preoperative variables and obturation techniques revealed significant differences in pulpal and periapical diagnosis, and percussion, and especially regarding age, root development stage, and PAI. Age was the only statistically significant preoperative variable associated with root growth (p < 0.05). Approximately, 60% of DEs requiring endodontic treatment had immature roots. Age being the most significant predisposing factor, early treatment provides the greatest opportunity for full root development.

Long-Term Outcomes of One-Stage Combined Posteroanterior Procedure and Laminoplasty-Alone for Multilevel Degenerative Cervical Myelopathy With Concomitant Anterior and Posterior Compression: A Propensity Score Matching Analysis of 8-year Follow-Up.

Retrospective cohort study. This study aimed to investigate the long-term outcomes of laminoplasty-alone (LP) and combined procedure (CP), consisting of laminoplasty and single-level anterior cervical discectomy and fusion, in comparable patients who had multilevel degenerative cervical myelopathy (MDCM) with concomitant anterior and posterior compression (CAPC). Consecutive MDCM patients with CAPC underwent LP or CP between 2012 and 2015 from a same surgical group were enrolled and followed up for a minimum of 8years. Preoperative demographic, radiological, and clinical variables were collected. Propensity score matching (PSM) analysis was performed to match patients with comparable conditions. The outcomes were evaluated by postoperative Japanese Orthopedic Association (JOA) score improvement, JOA recovery rate (JOARR) and complications. A total of 230 patients were included, of whom 146 underwent LP and 84 underwent CP. After PSM, 84 pairs of comparable patients were matched. The matched groups presented fair comparability in preoperative conditions. The CP group had significantly prolonged surgery time and greater blood loss. At the final follow-up, the postoperative JOA scores of LP and CP groups were 14.51 ± 1.79 and 15.47 ± 1.81 (P < 0.001) and the JOARR were 42.5% ± 53.3% and 68.5% ± 35.4%, respectively (P < 0.001). Three (3.6%) patients in the LP group underwent reoperations because of recurrent symptoms (P = 0.081). Both LP and CP demonstrated considerable long-term neurological recovery in patients with CAPC. The CP showed a significantly higher JOA improvement and JOARR. The combined decompression might be a safe and effective alternative in treating MDCM with CAPC in experienced hands.

Preoperative prediction of nodal status using clinical data and artificial intelligence derived mammogram features enabling abstention of sentinel lymph node biopsy in breast cancer.

Patients with clinically node-negative breast cancer have a negative sentinel lymph node status (pN0) in approximately 75% of cases and the necessity of routine surgical nodal staging by sentinel lymph node biopsy (SLNB) has been questioned. Previous prediction models for pN0 have included postoperative variables, thus defeating their purpose to spare patients non-beneficial axillary surgery. We aimed to develop a preoperative prediction model for pN0 and to evaluate the contribution of mammographic breast density and mammogram features derived by artificial intelligence for de-escalation of SLNB. This retrospective cohort study included 755 women with primary breast cancer. Mammograms were analyzed by commercially available artificial intelligence and automated systems. The additional predictive value of features was evaluated using logistic regression models including preoperative clinical variables and radiological tumor size. The final model was internally validated using bootstrap and externally validated in a separate cohort. A nomogram for prediction of pN0 was developed. The correlation between pathological tumor size and the preoperative radiological tumor size was calculated. Radiological tumor size was the strongest predictor of pN0 and included in a preoperative prediction model displaying an area under the curve of 0.68 (95% confidence interval: 0.63-0.72) in internal validation and 0.64 (95% confidence interval: 0.59-0.69) in external validation. Although the addition of mammographic features did not improve discrimination, the prediction model provided a 21% SLNB reduction rate when a false negative rate of 10% was accepted, reflecting the accepted false negative rate of SLNB. This study shows that the preoperatively available radiological tumor size might replace pathological tumor size as a key predictor in a preoperative prediction model for pN0. While the overall performance was not improved by mammographic features, one in five patients could be omitted from axillary surgery by applying the preoperative prediction model for nodal status. The nomogram visualizing the model could support preoperative patient-centered decision-making on the management of the axilla.

Would the one-stage combined approach lead to better long-term neurological outcomes than the posterior approach alone in multilevel degenerative cervical myelopathy patients with T2-Weighted increased signal intensity? An 8-year follow-up results and propensity score matching analysis

BackgroundT2-weighted increased signal intensity (ISI) is commonly recognized as a sign of more severe spinal cord lesions, usually accompanied by worse neurological deficits and possibly worse postoperative neurological recovery. The combined approach could achieve better decompression and better neurological recovery for multilevel degenerative cervical myelopathy (MDCM). The choice of surgical approach for MDCM with intramedullary T2-weighted ISI remains disputed. This study aimed to compare the neurological outcomes of posterior and one-stage combined posteroanterior approaches for MDCM with T2-weighted ISI.MethodsA total of 83 consecutive MDCM patients with confirmed ISI with at least three intervertebral segments operated between 2012 and 2014 were retrospectively enrolled. Preoperative demographic, radiological and clinical condition variables were collected, and neurological conditions were evaluated by the Japanese Orthopedic Assessment score (JOA) and Neck Disability Index (NDI). Propensity score matching analysis was conducted to produce pairs of patients with comparable preoperative conditions from the posterior-alone and combined groups. Both short-term and mid-term surgical outcomes were evaluated, including the JOA recovery rate (JOARR), NDI improvements, complications, and reoperations.ResultsA total of 83 patients were enrolled, of which 38 and 45 patients underwent posterior surgery alone and one-stage posteroanterior surgery, respectively. After propensity score matching, 38 pairs of comparable patients from the posterior and combined groups were matched. The matched groups presented similar preoperative clinical and radiological features and the mean follow-up duration were 111.6 ± 8.9 months. The preoperative JOA scores of the posterior and combined groups were 11.5 ± 2.2 and 11.1 ± 2.3, respectively (p = 0.613). The combined group presented with prolonged surgery duration(108.8 ± 28.0 and 186.1 ± 47.3 min, p = 0.028) and greater blood loss(276.3 ± 139.1 and 382.1 ± 283.1 ml, p<0.001). At short-term follow-up, the combined group presented a higher JOARR than the posterior group (posterior group: 50.7%±46.6%, combined group: 70.4%±20.3%, p = 0.024), while no significant difference in JOARR was observed between the groups at long-term follow-up (posterior group: 49.2%±48.5%, combined group: 59.6%±47.6%, p = 0.136). No significant difference was found in the overall complication and reoperation rates.ConclusionsFor MDCM patients with ISI, both posterior and one-stage posteroanterior approaches could achieve considerable neurological alleviations in short-term and long-term follow-up. With greater surgical trauma, the combined group presented better short-term JOARR but did not show higher efficacy in long-term neurological function preservation in patients with comparable preoperative conditions.

#1954 Effects of lanosterol synthase (LSS) gene on the development of acute kidney injury after cardiac surgery

Abstract Background and Aims Acute kidney injury (AKI) is a common post-cardiac surgery complication, significantly affecting morbidity and mortality. Recent studies reported that high plasma levels of endogenous ouabain (EO), a stress hormone secreted by the adrenal glands, are associated to worse kidney outcomes after cardiac surgery. Our group demonstrated that EO activity is affected by a missense variant (rs2254524, C -&amp;gt; A, Val642Leu) in Lanosterol Synthase (LSS) gene, an enzyme implicated in EO synthesis. The aim of this work is to analyze the relationship between this LSS polymorphism and the development of AKI after cardiac surgery. Method 1237 patients undergoing elective cardiac surgery were enrolled in the study. Preoperative biological samples were collected (Table 1). LSS genotypes were determined for each patient. The primary outcome was AKI development, according to KDIGO 2012 guidelines. Results 21.4% of patients developed AKI. Different preoperative clinical variables were analyzed, identifying five independent risk factors significantly correlated to AKI development in multivariate logistic regression analysis: age (p &amp;lt; 0.001), FE (p = 0.005), NYHA class (p &amp;lt; 0.001), reoperation (p = 0.002) and complex surgical intervention (p &amp;lt; 0.001), Table 2. No significant differences were observed between preoperative EO plasma levels and allelic variants of LSS gene and patients with the less common A allele were not associated to a more severe preoperative clinical presentation, expressed as EuroScore II value (AA 2.54 ± 3.86 vs AC 2.15 ± 2.52 vs CC 2.04 ± 2.73; p = ns). LSS minor variants turned out significantly associated with the incidence of AKI (AA = 29.3%; AC = 25.3%; CC = 17.2%; X2 p &amp;lt; 0.001—Fig. 1). This evidence remains significant after correction for covariates associated to AKI previously reported (Log regression p = 0.002; RR for AA variant: 2.09 (IC95% 1.15-3.78)) Conclusion Patients with at least one mutated allele of LSS variant have a higher probability of developing AKI after cardiac surgery. We think these results could be of interest to further understand cellular mechanisms underlying AKI development, especially in the cardiac surgery field.

Development and validation of machine learning models and nomograms for predicting the surgical difficulty of laparoscopic resection in rectal cancer

BackgroundThe objective of this study is to develop and validate a machine learning (ML) prediction model for the assessment of laparoscopic total mesorectal excision (LaTME) surgery difficulty, as well as to identify independent risk factors that influence surgical difficulty. Establishing a nomogram aims to assist clinical practitioners in formulating more effective surgical plans before the procedure.MethodsThis study included 186 patients with rectal cancer who underwent LaTME from January 2018 to December 2020. They were divided into a training cohort (n = 131) versus a validation cohort (n = 55). The difficulty of LaTME was defined based on Escal’s et al. scoring criteria with modifications. We utilized Lasso regression to screen the preoperative clinical characteristic variables and intraoperative information most relevant to surgical difficulty for the development and validation of four ML models: logistic regression (LR), support vector machine (SVM), random forest (RF), and decision tree (DT). The performance of the model was assessed based on the area under the receiver operating characteristic curve(AUC), sensitivity, specificity, and accuracy. Logistic regression-based column-line plots were created to visualize the predictive model. Consistency statistics (C-statistic) and calibration curves were used to discriminate and calibrate the nomogram, respectively.ResultsIn the validation cohort, all four ML models demonstrate good performance: SVM AUC = 0.987, RF AUC = 0.953, LR AUC = 0.950, and DT AUC = 0.904. To enhance visual evaluation, a logistic regression-based nomogram has been established. Predictive factors included in the nomogram are body mass index (BMI), distance between the tumor to the dentate line ≤ 10 cm, radiodensity of visceral adipose tissue (VAT), area of subcutaneous adipose tissue (SAT), tumor diameter >3 cm, and comorbid hypertension.ConclusionIn this study, four ML models based on intraoperative and preoperative risk factors and a nomogram based on logistic regression may be of help to surgeons in evaluating the surgical difficulty before operation and adopting appropriate responses and surgical protocols.

Develop a radiomics-based machine learning model to predict the stone-free rate post-percutaneous nephrolithotomy.

Radiomics and machine learning have been extensively utilized in the realm of urinary stones, particularly in forecasting stone treatment outcomes. The objective of this study was to integrate clinical variables and radiomic features to develop a machine learning model for predicting the stone-free rate (SFR) following percutaneous nephrolithotomy (PCNL).A total of 212 eligible patients who underwent PCNL surgery at the Second Affiliated Hospital of Nanchang University were included in a retrospective analysis. Preoperative clinical variables and non-contrast-enhanced CT images of all patients were collected, and radiomic features were extracted after delineating the stone ROI. Univariate analysis was conducted to identify clinical variables strongly correlated with the stone-free rate after PCNL, and the least absolute shrinkage and selection operator algorithm (lasso regression) was utilized to screen radiomic features. Four supervised machine learning algorithms, including Logistic Regression, Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Gradient Boosting Decision Tree (GBDT), were employed. The clinical variables with strong correlation and screened radiomic features were integrated into the four machine learning algorithms to construct a prediction model, and the receiver operating curve was plotted. The area under the receiver operating curve (AUC), the accuracy rate, the specificity, etc., were used to evaluate the predictive performance of the four models.After analyzing postoperative statistics, the stone-free rate following the procedure was found to be 70.3% (n = 149). Among the various clinical variables examined, factors, such as stone number, stone diameter, stone CT value, stone location, and history of stone surgery, were identified as statistically significant in relation to the stone-free rate after PCNL. A total of 121 radiomic features were extracted, and through lasso regression, 7 features most closely associated with the stone-free rate post-PCNL were identified. The predictive accuracy of different models (Logistic Regression, RF, XGBoost, and GBDT) for determining the stone-free rate after PCNL was evaluated, yielding accuracies of 78.1%, 76.6%, 75.0%, and 73.4%, respectively. The corresponding area under the curve AUC (95%CI) were 0.85 (0.83-0.89), 0.81 (0.76-0.85), 0.82 (0.78-0.85), and 0.77 (0.73-0.81), positioning these models among the top performers in logistic regression prediction. In terms of predictive importance scores, the key factors identified by the logistic regression model were number of stone, zone percentage, stone diameter, and surface area. Similarly, the RF model highlighted number of stone, stone CT value, stone diameter, and surface area as the top predictors.Among the four machine learning models, the logistic regression model demonstrated the highest accuracy and discrimination ability in predicting the stone-free rate following PCNL. In comparison to XGBoost and GBDT, RF also exhibited superior accuracy and a certain level of discrimination ability. However, based on the performance of all four models, logistic regression is more likely to aid in clinical decision-making by assisting clinicians in diagnosing PCNL in patients. This enables us to effectively predict the presence of residual stones post-surgery and ultimately select patients who are suitable candidates for PCNL.

Dural Sac Cross-sectional area change from preoperatively and up to 2 years after decompressive surgery for central lumbar spinal stenosis: investigation of operated levels, data from the NORDSTEN study.

The aim of the present study was to investigate how canal area size changed from before surgery and up to 2 years after decompressive lumbar surgery lumbar spinal stenosis. Further, to investigate if an area change postoperatively (between 3 months to 2 years) was associated with any preoperative demographic, clinical or MRI variables or surgical method used. The present study is analysis of data from the NORDSTEN- SST trial where 437 patients were randomized to one of three mini-invasive surgical methods for lumbar spinal stenosis. The patients underwent MRI examination of the lumbar spine before surgery, and 3 and 24 months after surgery. For all operated segments the dural sac cross-sectional area (DSCA) was measured in mm2. Baseline factors collected included age, gender, BMI and smoking habits. Furthermore, surgical method, index level, number of levels operated, all levels operated on and baseline Schizas grade were also included in the analysis. 437 patients were enrolled in the NORDSTEN-SST trial, whereof 310 (71%) had MRI at 3 months and 2 years. Mean DSCA at index level was 52.0mm2 (SD 21.2) at baseline, at 3 months it increased to 117.2mm2 (SD 43.0) and after 2 years the area was 127.7mm2 (SD 52.5). Surgical method, level operated on or Schizas did not influence change in DSCA from 3 to 24 months follow-up. The spinal canal area after lumbar decompressive surgery for lumbar spinal stenosis increased from baseline to 3 months after surgery and remained thereafter unchanged 2 years postoperatively.

701 A Modified Frailty Index to Predict Adverse Outcomes After Decompressive Hemicraniectomy for Acute Ischemic Stroke

INTRODUCTION: Surgical decision-making for decompressive hemicraniectomy (DHC) is challenging because of the heterogeneity of health status and the paucity of tools for predicting the operative risk of DHC for malignant edema following acute infarction. METHODS: The 2008–2018 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing DHC for Acute ischemic stroke (AIS) based on Current Procedural Terminology (CPT) codes. We used a modified frailty index (mFI) based on eleven preoperative clinical NSQIP variables. The outcomes assessed were 30-day occurrences of adverse events. RESULTS: A total of 394 patients were identified in the database, there were 55 (14%) patients with mFI 0, 118 patients (30%) with mFI 0.09, 115(29.2 %) with mFI 0.18 and 106 (27%) patients with mFI = 0.27. The rate of return to the operating room for a second procedure significantly increased from 4/55 (7.3%) in patients with mFI 0 to 23/106 (31.1%) in patients with mFI = 0.27. The discharge disposition was significantly different in patients with higher mFI (mFI &gt; 0.27), with only 6/106 (5.7%) discharged to home versus 8/55 (14.5%) with mFI 0. Multivariate logistic regression analysis showed that compared to age, gender, ASA class, and pre albumin levels, mFI was a better predictor of the development of pneumonia (OR 6.278, 95 % CI 1.8, 22.0, p = 0.004) and return to the operating room (OR 4.0, 95 % CI 1.2 ,13.4, p = 0.02). CONCLUSIONS: A higher mFI was associated with an increased risk of return to the operating room and worse discharge disposition. The mFI is based on easily identifiable patient characteristics and can be an additional tool to improve perioperative risk stratification in elderly patients considered for DHC after AIS.

Clinical Outcomes and Echocardiographic Predictors of Reintervention After Interrupted Aortic Arch Repair.

Left ventricular outflow tract obstruction (LVOTO) remains a significant complication after primary repair of interrupted aortic arch with ventricular septal defect (IAA-VSD). Clinical and echocardiographic predictors for LVOTO reoperation are controversial and procedures to prophylactically prevent future LVOTO are not reliable. However, it is important to identify the patients at risk for future LVOTO intervention after repair of IAA-VSD. Patients who underwent single-stage IAA-VSD repair at our center 2006-2021 were retrospectively reviewed, excluding patients with associated cardiac lesions. Two-dimensional measurements, LVOT gradients, and 4-chamber (4C) and short-axis (SAXM) strain were obtained from preoperative and predischarge echocardiograms. Univariate risk analysis for LVOTO reoperation was performed using unpaired t-test. Thirty patients were included with 21 (70%) IAA subtype B and mean weight at surgery 3.0kg. Repair included aortic arch patch augmentation in 20 patients and subaortic obstruction intervention in three patients. Seven (23%) required reoperations for LVOTO. Patient characteristics were similar between patients who required LVOT reoperation and those who did not. Patch augmentation was not associated with LVOTO reintervention. Patients requiring reintervention had significantly smaller LVOT AP diameter preoperatively and at discharge, and higher LVOT velocity, smaller AV annular diameter, and ascending aortic diameter at discharge. There was an association between LVOT-indexed cross-sectional area (CSAcm2/BSAm2) ≤ 0.7 and reintervention. There was no significant difference in 4C or SAXM strain in patients requiring reintervention. LVOTO reoperation was not associated with preoperative clinical or surgical variables but was associated with smaller LVOT on preoperative echo and smaller LVOT, smaller AV annular diameter, and increased LVOT velocity at discharge.

The factors impacting on Gleason score upgrading in prostate cancer with initial low Gleason scores

BackgroundThis study aims to investigate the factors contributing to the discrepancy in between biopsy Gleason score (GS) and radical prostatectomy GS in patients diagnosed with prostate cancer. Methods341 patients who underwent radical prostatectomy from 2011/04 to 2020/12 were identified. 102 Patients with initial GS of six after biopsy were enrolled. Preoperative clinical variables and pathological variables were also obtained and assessed. The optimal cut-off points for significant continuous variables were identified by the area under the receiver operating characteristic curve. ResultsUpgrading was observed in 63 patients and non-upgrading in 39 patients. In the multiple variables assessed, smaller prostate volume (PV) (p value = 0.0007), prostate specific antigen density (PSAD) (p value = 0.0055), positive surgical margins (p value = 0.0062) and pathological perineural invasion (p value = 0.0038) were significant predictors of GS upgrading. To further explore preclinical variables, a cut-off value for PV (≤ 38 ml, p value = 0.0017) and PSAD (≥ 0.26 ng/ml2, p value = 0.0013) were identified to be associated with GS upgrading. ConclusionsSmaller PV and elevated PSAD are associated with increased risk of GS upgrading, whereas lead-time bias is not. A cut-off value of PV < 38 ml and PSAD > 0.26 ng/ml2 were further identified to be associated with pathological GS upgrading.

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques. Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified. A total of 7473 patients were included (72.1% male, mean age 66.2±13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean:0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE:0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009). Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

Cerebral regional oxygen saturation as a predictive parameter for preoperative heart failure and delayed hemodynamic recovery in transcutaneous aortic valve implantation: a retrospective cohort study.

This study aimed to investigate the relationship of perioperative cerebral regional oxygen saturation (rSO2) with various preoperative clinical variables and hemodynamic changes during transfemoral transcatheter aortic valve implantation (TAVI) under general anesthesia. We retrospectively analyzed cerebral rSO2 values from left-hemisphere measurements obtained using near-infrared spectroscopy (O3™ regional oximetry) at five time points: pre-induction, the start of the procedure, the start of valve deployment, time of lowest cerebral rSO2 value during valve deployment, and the end of the procedure. This study included 91 patients (60 with balloon-expandable valves and 31 with self-expandable valves). The baseline cerebral rSO2 values were correlated with B-type natriuretic peptide, hemoglobin, fractional shortening, ejection fraction, left ventricular mass index, left ventricular end-systolic diameter, STS risk of mortality, and STS morbidity or mortality. The patients who took longer to recover their systolic blood pressure to 90 mmHg after valve deployment with a balloon-expandable valve (group B) had lower cerebral rSO2 values during deployment compared to patients with faster recovery with balloon-expandable valve (group A) and with self-expandable valve (group C). Baseline cerebral rSO2 is associated with preoperative variables related to cardiac failure and function, and a significant decline during valve deployment may indicate a risk of prolonged hypotension during TAVI.

Analysis of Preoperative Risk Factors for Early Recurrence in Patients After Hepatic Resection for Intrahepatic Cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) has a poor prognosis even after curative-intent hepatic resection due to a high recurrence rate. The aim of this study was to investigate preoperative risk factors for early recurrence after surgery for ICC, which may help to identify patients who need preoperative chemotherapy. We retrospectively analyzed 51 patients who had undergone primary surgery for ICC. We investigated the association of preoperative clinical variables with recurrence within 1year after resection for ICC. We then created a high-risk ICC score using the identified preoperative factors and investigated the association of the score with disease-free and overall survival. Recurrence within 1year after surgery for ICC was significantly associated with poor overall survival (P < .01). In the multivariate analysis, preoperative tumor size > 5cm (P = .03) and elevated C-reactive protein-to-albumin ratio (CAR) (P = .04) were significantly associated with recurrence within 1year after surgery. A high-risk ICC score of 2 was associated with poor disease-free survival (P < .01) and overall survival (P = .02) compared with a score of 0 or 1. Our high-risk ICC score, combining preoperative tumor size and CAR, can be an indicator of early recurrence and poor survival in patients after hepatic resection for ICC. Our findings may provide better preoperative risk stratification of patients with ICC, and the high-risk ICC patients may benefit from preoperative therapy.

Prognostic impact of extramural venous invasion detected by contrast-enhanced CT colonography in colon cancer.

The impact of computed tomography (CT)-detected extramural venous invasion on the recurrence of colon cancer is not fully understood. The aim of this study was to investigate the clinical significance of extramural venous invasion diagnosed before surgery by contrast-enhanced CT colonography using three-dimensional multiplanar reconstruction images. Patients with colon cancer staged greater than or equal to T2 and/or stage I-III who underwent contrast-enhanced CT colonography between 2013 and 2018 at the National Cancer Center Hospital in Japan were retrospectively investigated for CT-detected extramural venous invasion. Inter-observer agreement for the detection of CT-detected extramural venous invasion was evaluated and Kaplan-Meier survival curves were plotted for recurrence-free survival using CT-TNM staging and CT-detected extramural venous invasion. Preoperative clinical variables were analysed using Cox regression for recurrence-free survival. Out of 922 eligible patients, 544 cases were analysed (50 (9.2 per cent) were diagnosed as positive for CT-detected extramural venous invasion and 494 (90.8 per cent) were diagnosed as negative for CT-detected extramural venous invasion). The inter-observer agreement for CT-detected extramural venous invasion had a κ coefficient of 0.830. The group positive for CT-detected extramural venous invasion had a median follow-up of 62.1 months, whereas the group negative for CT-detected extramural venous invasion had a median follow-up of 60.7 months. When CT-TNM stage was stratified according to CT-detected extramural venous invasion status, CT-T3 N(-)extramural venous invasion(+) had a poor prognosis compared with CT-T3 N(-)extramural venous invasion(-) and CT-stage I (5-year recurrence-free survival of 50.6 versus 89.3 and 90.1 per cent respectively; P < 0.001). In CT-stage III, the group positive for CT-detected extramural venous invasion also had a poor prognosis compared with the group negative for CT-detected extramural venous invasion (5-year recurrence-free survival of 52.0 versus 78.5 per cent respectively; P = 0.003). Multivariable analysis revealed that recurrence was associated with CT-T4 (HR 3.10, 95 per cent c.i. 1.85 to 5.20; P < 0.001) and CT-detected extramural venous invasion (HR 3.08, 95 per cent c.i. 1.90 to 5.00; P < 0.001). CT-detected extramural venous invasion was found to be an independent predictor of recurrence and could be used in combination with preoperative TNM staging to identify patients at high risk of recurrence.

Preoperative risk factors for nonsatisfaction after lumbar interbody fusion

IntroductionLow back pain (LBP) is a common cause of impaired quality of life and disability and studies regarding surgical management of patients with LBP show a high variation in patient-reported success rate. Research questionTo find valuable preoperative clinical risk factors and variables associated with a non-satisfactory patient-reported outcome following surgery. Materials and methodsThe Danish surgical spine database (DaneSpine) was used to collect eight years of pre- and postoperative data on patients undergoing single-level fusions with either posterior- (PLIF) or transforaminal lumbar interbody fusions (TLIF). The primary outcome was patient nonsatisfaction. We collected data on European Quality of Life–5 Dimensions (EQ-5D), visual analogue scale (VAS), Oswestry Disability Index (ODI) score, pain intensity, duration of back pain, previous discectomy, and expectations regarding return to work after surgery at 2-year follow-up. ResultsThe cohort included 453 patients of which 19% reported treatment nonsatisfaction. The nonsatisfaction group demonstrated higher preoperative VAS scores for back pain (75 ± 19 vs. 68 ± 21, p = 0.006) and leg pain (65 ± 25 vs. 58 ± 28, p = 0.004). The preoperative EQ-5D score was significantly lower in the nonsatisfaction group (0.203 + 0.262 vs. 0.291 ± 0.312, p = 0.016). There was no statistical significance between patient nonsatisfaction and preoperative ODI score, age, body mass index, duration of back pain or expectations regarding return to work after surgery. Discussion and conclusionLow preoperative EQ-5D scores and high VAS leg and back pain scores were statistically significant with patient nonsatisfaction following surgery and may prove to be valuable tools in the preoperative screening and alignment of patient expectations.