Scheduled Surgery Research Articles

Photoplethysmography waveform analysis for classification of vascular tone and arterial blood pressure: Study based on neural networks

To test whether a Shallow Neural Network (S-NN) can detect and classify vascular tone dependent changes in arterial blood pressure (ABP) by advanced photopletysmographic (PPG) waveform analysis. PPG and invasive ABP signals were recorded in 26 patients undergoing scheduled general surgery. We studied the occurrence of episodes of hypertension (systolic arterial pressure (SAP) >140 mmHg), normotension and hypotension (SAP < 90 mmHg). Vascular tone according to PPG was classified in two ways: 1) By visual inspection of changes in PPG waveform amplitude and dichrotic notch position; where Classes I-II represent vasoconstriction (notch placed >50% of PPG amplitude in small amplitude waves), Class III normal vascular tone (notch placed between 20-50% of PPG amplitude in normal waves) and Classes IV-V-VI vasodilation (notch <20% of PPG amplitude in large waves). 2) By an automated analysis, using S-NN trained and validated system that combines seven PPG derived parameters. The visual assessment was precise in detecting hypotension (sensitivity 91%, specificity 86% and accuracy 88%) and hypertension (sensitivity 93%, specificity 88% and accuracy 90%). Normotension presented as a visual Class III (III-III) (median and 1st-3rd quartiles), hypotension as a Class V (IV-VI) and hypertension as a Class II (I-III); all p < .0001. The automated S-NN performed well in classifying ABP conditions. The percentage of data with correct classification by S-ANN was 83% for normotension, 94% for hypotension, and 90% for hypertension. Changes in ABP were correctly classified automatically by S-NN analysis of the PPG waveform contour.

Patient, clinical, surgical, and institutional factors associated with length of stay in scheduled degenerative thoracolumbar spine surgery: National Multicenter Cohort Analysis from the Canadian Spine Outcomes and Research Network.

Length of stay (LOS) is a contributor to costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for thoracolumbar degenerative pathology. The secondary objective was to examine variability in LOS and institutional strategies used to decrease LOS. This is a retrospective study of prospectively collected data from a multicentric cohort enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective thoracolumbar surgery (discectomy [1 or 2 levels], laminectomy [1 or 2 levels], and posterior instrumented fusion [up to 5 levels]). Prolonged LOS was defined as LOS greater than the median. Logistic regression models were used to determine factors associated with prolonged LOS for each procedure. A survey was sent to the principal investigators of the participating healthcare institutions to understand institutional practices that are used to decrease LOS. A total of 3700 patients were included (967 discectomies, 1094 laminectomies, and 1639 fusions). The median LOSs for discectomy, laminectomy, and fusion were 0.0 (IQR 1.0), 1.0 (IQR 2.0), and 4.0 (IQR 2.0) days, respectively. On multivariable analysis, predictors of prolonged LOS for discectomy were having more leg pain, higher Oswestry Disability Index (ODI) scores, symptom duration more than 2 years, having undergone an open procedure, occurrence of an adverse event (AE), and treatment at an institution without protocols to reduce LOS (p < 0.05). Predictors of prolonged LOS for laminectomy were increased age, living alone, higher ODI scores, higher BMI, open procedures, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). For posterior instrumented fusion, predictors of prolonged LOS were older age, living alone, more comorbidities, higher ODI scores, longer operative time, AEs, and treatment at an institution without protocols to reduce LOS (p < 0.05). The laminectomy group had the largest variability in LOS (SD 4.4 days, range 0-133 days). Three hundred fifty-four patients (22%) had an LOS above the 75th percentile. Ten institutions (53%) had either Enhanced Recovery After Surgery or standardized protocols in place. Among the factors identified in this study, worse baseline ODI scores, experiencing AEs, and treatment at an institution without protocols aimed at reducing LOS were predictive of prolonged LOS in all surgical groups. The laminectomy group had the largest variability in LOS.

Hard cataract or heart attack

Miscommunication arises when interacting members connect, but one or more of its members in the communication chain does not fully understand what has been conveyed. This can happen for a variety of reasons, including the initiator's inappropriate word selection, existence of communication barrier between the initiator and receiver, the receiver's misperception, and less frequently, the receiver being “off-target” to the communication chain. This case involves a 54-year-old woman with no known comorbid conditions who experienced an acute panic attack just before the start of scheduled cataract surgery, which was managed with abandonment of surgery followed by monitoring and treatment in the intensive care, conducting the departmental root cause analysis, and subsequent performance of uneventful surgery with satisfactory outcome after addressing the root cause.

Accuracy of telemedicine for diagnosis and pre-operative assessment of pediatric penile conditions

Patients with penile conditions comprise a significant proportion of any pediatric urology practice, and physical examination is the mainstay of diagnosis for such conditions. While the rapid adoption of telemedicine (TM) facilitated access to pediatric urology care during the pandemic, the accuracy of TM-based diagnosis for pediatric penile anatomy and pathology has not been studied. Our aim was to characterize the diagnostic accuracy of TM-based evaluation of pediatric penile conditions by comparing diagnosis during the initial virtual visit (VV) with a subsequent in-person visit (IPV). We also sought to assess the agreement between scheduled and actual surgical procedure performed. A single-institution prospective database of male patients less than 21 years of age who presented for evaluation of penile conditions between August 2020 and December 2021 was analyzed. Patients were included if they had an IPV with the same pediatric urologist within 12 months of the initial VV. Diagnostic concordance was based on a surgeon-reported survey of specific penile diagnoses, completed at both initial VV and follow-up IPV. Surgical concordance was assessed based on the proposed versus billed CPT code(s). Median age among 158 patients was 10.6 months. The most frequent VV diagnoses were penile adhesions (n=37), phimosis (n=26), "other" (n=24), post-circumcision redundancy (n=18), and buried penis (n=14). Initial VV and subsequent IPV diagnoses were concordant in 40.5% (64/158); 40/158 (25%) had partial concordance (at least one diagnosis matched). There was no difference in age, race, ethnicity, median time between visits, or device type between patients with concordant vs. discordant diagnoses. Of 102 patients who underwent surgery, 44 had VV only while 58 had IPV prior to surgery. Concordance of scheduled versus actual penile surgery was 90.9% in those patients who only had a VV prior to surgery. Overall, surgery concordance was lower among those with hypospadias repairs vs. non-hypospadias surgery (79.4% vs. 92.6%, p=0.05). Among pediatric patients being evaluated by TM for penile conditions, there was poor agreement between VV-based and IPV-based diagnoses. However, besides hypospadias repairs, agreement between planned and actual surgical procedures performed was high, suggesting that TM-based assessment is generally adequate for surgical planning in this population. These findings leave open the possibility that, among patients not scheduled for surgery or IPV, certain conditions might be misdiagnosed or missed entirely.

Incidence of asymptomatic SARS-CoV-2 infection in children undergoing elective otolaryngologic surgery throughout the COVID-19 pandemic.

Children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are less clinically affected than adults, with most cases presenting as asymptomatic or mildly symptomatic. However, true rates of asymptomatic SARS-CoV-2 infection in children remain unclear. We sought to examine rates of SARS-CoV-2 in asymptomatic children and the role of children in transmission. We performed a retrospective review of patients between 6months and 17 years of age who underwent elective or semi-elective otolaryngologic surgery with physicians affiliated with Weill Cornell Medicine between May 15, 2020 and March 31, 2022. Patients were included if they received molecular assay testing for SARS-CoV-2 without SARS-CoV-2 symptoms within 5 days of scheduled surgery. SARS-CoV-2 infection status, exposure, clinical symptoms, demographic data, and insurance status were recorded. 1047 patients met inclusion criteria. Thirteen positive cases (1.24%) were identified in the study population. Six cases occurred between December 2021 and February 2022 following the classification of the omicron variant as a variant of concern in November 2021. Five of the 13 cases occurred in children under 2 years of age. Seven patients were male, and five were female. Residences spanned all five boroughs of New York City and the surrounding metropolitan area. Throughout the pandemic, children have had a low rate of asymptomatic disease and likely pose a low risk of transmission of SARS-CoV-2 to the general population. Our results suggest that testing of asymptomatic children is a low-yield practice that is unlikely to influence rates of SARS-CoV-2 in the general population. 3.

Robotic-Assisted Total Knee Arthroplasty: What are Patients’ Perspectives, Understanding and Expectations?

BackgroundThe rate of using robotic-assisted total knee arthroplasty (RA-TKA) has increased markedly. Understanding how patients view the role of robotics during total knee arthroplasty (TKA) informs shared decision making and facilitate efforts to appropriately educate patients regarding the risks and benefits of robotic assistance. MethodsA self-administered questionnaire was completed by 440 potential TKA patients at the time of their surgery scheduling. Participants answered 25 questions regarding RA-TKA, socioeconomic factors, and their willingness to pay (WTP) for RA-TKA. Logistic regressions were used to determine if population characteristics and surgeon preferences influenced the patients’ perceptions of RA-TKA. ResultsThere were 39.7% of respondents who said that they had no knowledge regarding RA-TKA. Only 40.7% of participants had expressed a desire for RA-TKA to be used. There were 8.7% who were WTP extra for the use of RA-TKA. Participants believed that the main 3 benefits of RA-TKA compared to conventional methods were: more accurate implant placement (56.2%); better results (49.0%); and faster recovery (32.1%). The main 3 patient concerns were harm from malfunction (55.2%), reduced surgeon role in the procedure (48.1%), and lack of supportive research (28.3%). Surgeon preference of RA-TKA was associated with patient’s willingness to have RA-TKA (odds ratio 4.60, confidence interval 2.98-7.81, P < .001), and with WTP extra for RA-TKA (odds ratio 2.05, confidence interval: 1.01-4.26, P = .049). ConclusionPatient knowledge regarding RA-TKA is limited. Nonpeer-reviewed online information may make prospective TKA candidates vulnerable to misinformation and aggressive advertising. The challenge for orthopaedic surgeons is to re-establish control and reliably educate patients about the proven advantages and disadvantages of this emerging technology.

Benefits of IV Clonidine in Premedication on Sympathetic Hyperactivity Related to Surgical Incision

Background: Clonidine stimulates the α2 receptors of the sympathetic nervous system which have a negative presynaptic feedback effect inducing a reduction in the secretion of adrenaline and noradrenaline. The main objective of our study was to evaluate the beneficial effects of clonidine on the hemodynamic response to surgical incision. Patients and Methods: This was a prospective, single-center, randomized, single-blind clinical trial that took place over a period of 4 months in the anesthesia department of the Essos hospital center in Yaoundé. All patients over the age of 18, ASA I or II, admitted for scheduled surgery were included in the study. The patients were randomly divided into two groups by drawing lots: group A (clonidine) and group B (non-clonidine). All patients in group A received clonidine IV (3μg/kg). Heart rate, systolic blood pressure, and diastolic blood pressure were observed at different times during the surgical procedure. Results: During the study period, 35 met the inclusion criteria: 20 patients for group A and 15 patients for group B. The average age was 34 years. The sex ratio was in favor of the male gender in both groups: 2.3 in group A and 2.7 in group B. ASA class 1 was the most represented (74.3%); visceral surgery most performed of all specialties in the two groups 55% (n=11) for group A and 53% (n=8) for group B. The systolic and diastolic arterial pressure curves are parallel in the two groups. There is a slight variation in PAS and PAD in group A "clonidine" compared to the baseline values. A tendency towards systolic arterial hypertension is observed in the “non-clonidine” control group. The heart rate remains stable in group A, while tachycardia is observed at the same time for the participants in group B. Conclusion: Clonidine is an alpha 2 adrenergic receptor agonist which makes it possible to limit the hypersecretion of catecholamines, potentially deleterious for the fragile patient, at the surgical incision.

Pre-Anesthetic Consultation at the University Clinics of Kinshasa: Patient Profile, Type of Surgery, Anesthetic Protocol

<i>Introduction</i>: PAC is an element of anesthetic safety that makes it possible to collect information about the patient (history, physical examination), to assess the operative risk, to choose the technique of anesthesia and perioperative care best suited to the clinical condition of the patient. General objective was to describe the practice of PAC at the University Clinics of Kinshasa. <i>Methods</i>: This is a cross-sectional descriptive study carried out in Kinshasa from 1 January to 31 December 2021 (12 months), at the Department of Anesthesia and Resuscitation (ARD) of the University Clinics of Kinshasa. It involved all patients who had been consulted as part of a scheduled surgery, i.e. 443 patients. <i>Results</i>: The average age was 36.6 years with extremes of 7 days and 91 years. The female sex was predominant with 55.3%. Hypertension was the most found medical history in 13.5%. Gyneco-obstetric surgery (22.3%), otolaryngological surgery (13.8%) and neurosurgery (10.2%) were the most common of the surgical types. ASA I and ASA II patients were the most common (85.3%). General anesthesia accounted for 59% with Sevoflurane offered in 91% of general anesthesia. Spinal anesthesia accounted for 35.7%. <i>Conclusion</i>: The PAC is regularly performed in our environment in case of scheduled surgery and concerns all available surgical specialties.

Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic

The American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic. To investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures. This multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included. The primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery. A total of 988 436 patients were identified (mean [SD] age, 54.5 [16.1] years; 574 683 women [58.1%]), of whom 823 746 underwent scheduled surgery before COVID-19 and 164 690 had surgery during COVID-19. On multivariable analysis, the odds of outpatient surgery during COVID-19 (vs 2019) were higher in patients who underwent mastectomy for cancer (odds ratio [OR], 2.49 [95% CI, 2.33-2.67]), minimally invasive adrenalectomy (OR, 1.93 [95% CI, 1.34-2.77]), thyroid lobectomy (OR, 1.43 [95% CI, 1.32-1.54]), breast lumpectomy (OR, 1.34 [95% CI, 1.23-1.46]), minimally invasive ventral hernia repair (OR, 1.21 [95% CI, 1.15-1.27]), minimally invasive sleeve gastrectomy (OR, 2.56 [95% CI, 1.89-3.48]), parathyroidectomy (OR, 1.24 [95% CI, 1.14-1.34]), and total thyroidectomy (OR, 1.53 [95% CI, 1.42-1.65]). These odds were all greater than those observed for 2019 vs 2018, 2018 vs 2017, and 2017 vs 2016, suggesting that an accelerated increase in outpatient surgery rates in 2020 occurred as a consequence of COVID-19, rather than a continuation of secular trends. Despite these findings, only 4 procedures had a clinically meaningful (≥10%) overall increase in outpatient surgery rates during the study period: mastectomy for cancer (+19.4%), thyroid lobectomy (+14.7%), minimally invasive ventral hernia repair (+10.6%), and parathyroidectomy (+10.0%). In this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.

Genetic Algorithm for Solving the No-Wait Three-Stage Surgery Scheduling Problem.

In this research, we consider a deterministic three-stage operating room surgery scheduling problem. The three successive stages are pre-surgery, surgery, and post-surgery. The no-wait constraint is considered among the three stages. Surgeries are known in advance (elective). Multiple resources are considered throughout the surgical process: PHU (preoperative holding unit) beds in the first stage, ORs (operating rooms) in the second stage, and PACU (post-anesthesia care unit) beds in the third stage. The objective is to minimize the makespan. The makespan is defined as the maximum end time of the last activity in stage 3. Minimizing the makespan not only maximizes the utilization of ORs but also improves patient satisfaction by allowing treatments to be delivered to patients in a timely manner. We proposed a genetic algorithm (GA) for solving the operating room scheduling problem. Randomly generated problem instances were tested to evaluate the performance of the proposed GA. The computational results show that overall, the GA deviated from the lower bound (LB) by 3.25% on average, and the average computation time of the GA was 10.71 s. We conclude that the GA can efficiently find near-optimal solutions to the daily three-stage operating room surgery scheduling problem.

Effects of Pre-operative Physical Therapy on Functional Capacity, Kinesiophobia, and Post-operative ICU Stay in Coronary Artery Bypass Grafting Candidates

Objectives: This study was done to find out the impact of a pre-operative physical therapy plan with inspiratory muscle training on functional capacity, kinesiophobia, and post-operative intensive care unit (ICU) stay in subjects with coronary artery disease (CAD) candidates for coronary artery bypass grafting (CABG). Methods: Fifty subjects who fulfilled the inclusion criteria were recruited and randomly distributed into the intervention and control group by concealed envelop method. Participants in the experimental group were provided with inspiratory muscle training (IMT) with breathing exercises and chest clearance techniques, while the control group received breathing exercises and chest clearance techniques. Both groups received three treatment sessions before their scheduled surgery. The assessment was done at three-time intervals: At baseline, after three sessions, and after surgery. The outcome measures were oxygen saturation, heart rate, respiratory rate, Borg scale of perceived exertion (Borg PRE), Tampa scale of kinesiophobia for the heart (TSKH), and days spent at ICU after CABG. Results: Oxygen saturation, respiratory rate, functional capacity, and pulmonary endurance improved significantly among the treatment groups with a P&lt;0.001 and a large effect size. The pulse rate showed no significant improvement; P and effect size were 0.38 and 0.60, respectively. Kinesiophobia and ICU stay also showed significant changes with a P&lt;0.001. The effect size was large for both kinesiophobia and ICU stay. Discussion: IMT as a component of a pre-operative physical therapy plan can improve oxygen saturation, respiratory rate, functional capacity, and pulmonary endurance in CAD patients going for CABG. IMT reduces the level of kinesiophobia and duration of ICU stay after CABG.

Commentary: Post-pandemic lessons learnt regarding triage, mitigation, and management of emergency ocular conditions.

Commentary: Post-pandemic lessons learnt regarding triage, mitigation, and management of emergency ocular conditions.

The Green Surgical Block 4.0: Automation of the operating theatre's climate conditions through a real-time patient-flow solution

The energy consumed by surgery units constitutes a staggering part of the overall healthcare carbon footprint. Partly due to the demanding climate conditions necessitated by operating theatres (OTs), energy is also wasted because of poorly managed heating, ventilation and air-conditioning systems (HVACs) that consume up to 57% of the total energy used in a hospital. With their goal of optimising OTs' performance and reducing patient waiting lists, heads of surgery units worldwide do not dare to risk cancelling scheduled surgery because of problems with the OT environment conditions (ie temperature, humidity, pressure). Current solutions are monolithic, complex and completely disconnected from healthcare logic, failing to take into account the idiosyncrasy of hospitals. This article presents an innovation that uses real-time patient flow data to automate and optimise the OT's climate conditions.

Quantification of new intracerebral lesions on diffusion-weighted magnetic resonance imaging after transcarotid artery revascularization for treatment of carotid artery stenosis

Transcarotid artery revascularization (TCAR) has been used with increasing prevalence for treatment of carotid artery stenosis. TCAR holds potential benefits over traditional carotid endarterectomy (CEA) or transfemoral carotid artery stenting by its nature of being less invasive than CEA but more neuroprotective than transfemoral carotid artery stenting. The purpose of this pilot study is to evaluate the effectiveness of the neuroprotection system of TCAR with flow reversal by quantifying the incidence and degree of new intracerebral lesions using diffusion-weighted magnetic resonance imaging (DW-MRI). This study is the first to evaluate these findings in a real-world, high-risk cohort, who would have been excluded from the ROADSTER and ENROUTE transcarotid neuroprotection system DW-MRI studies. Patients undergoing unilateral TCAR for symptomatic or asymptomatic severe internal carotid artery disease were eligible and prospectively enrolled in the study. All patients had high risk features, including comorbidities or medications, which excluded them from industry-sponsored DW-MRI trials. Patients underwent a preoperative DW-MRI to obtain a baseline intracerebral evaluation within 1 week of the scheduled surgery. The follow-up DW-MRI occurred within 48hours postoperatively. The primary outcome was new, acute postoperative lesion(s) identified on DW-MRI. Secondary outcomes include any major stroke, myocardial infarction, or death during hospitalization. Five consecutive patients underwent TCAR with preoperative and postoperative imaging. All five patients were on dual antiplatelet therapy before their procedure and verified to be therapeutic on these agents. All patients underwent a right-sided TCAR and three were symptomatic as the indication for their procedure. All five patients demonstrated chronic lesions on the preoperative DW-MRI. Technical success was achieved in all five patients, with one operative complication involving a dissection of the common carotid at the access site, which was stented using the TCAR system. Postoperative DW-MRI did not identify any new intracerebral lesions in any patient following the procedure. No patient had a stroke, myocardial infarction, or death during hospitalization. In this real-world, high-risk cohort, TCAR was completed with no evidence of new, postoperative DW-MRI lesions. These data further demonstrate that TCAR with flow reversal is an effective neuroprotective strategy for carotid revascularization. Further study is warranted to evaluate DW-MRI differences between TCAR and CEA.

Incidents and Accidents during Anesthesia in Scheduled and Emergency Surgery at the Gabriel Toure Hospital

Introduction: The aim of this study was to evaluate the incidents and accidents during anesthesia in surgery at the Gabriel TOURE hospital. Methodology: This was a descriptive prospective study of anesthetic incidents and accidents that took place in the anesthesia department of the Gabriel TOURE hospital on the operating sites of programs and surgical and gyneco-obstetric emergencies ranging from the 1st January to March 31, 2021. Our study focused on all patients who underwent emergency and scheduled anesthesia during the period. Included were all patients with at least one accident or incident, All patients who did not present accidents and incidents or who refused to participate in the study were not included. The data was collected on the survey sheets and analyzed using the EPI INFO 7 software. Data entry was made using Windows XP software. Results: Over a period of 03 months, we collected 741 patients operated on in the operating theaters of the Gabriel TOURE hospital, of which 100 patients presented accidents/incidents in scheduled and emergency surgery, i.e. a rate of 13.49%. Urgent surgery represents 15.23% of incidents or accidents. Conclusion: We were able to take stock of several elements related to our practice of anesthesia. One of the essential interests of this work was the comparison of a population of subjects having "been victims of an anesthesia accident to the whole population anesthetized in the same structures, by the same practitioners, over the same period of study”.

Rzadki przypadek podwójnej przegrody międzyprzedsionkowej u 4-letniego chłopca z dużym ubytkiem przegrody międzyprzedsionkowej typu ostium secundum

The work presents a case of a 4-year-old boy diagnosed with a large atrial septal defect type ostium secundum (ASD2) and additional abnormal structures in the direction of the left atrium in the echocardiogram. The patient was qualified for interventional defect closure, however, in the transoesophageal echocardiography, in addition to a very large ASD2 (approx. 2 cm), a double interatrial septum was diagnosed. The extra wall layer was parallel to the atrial septum and did not obstruct blood flow from the pulmonary veins or through the mitral valve. No signs of clotting material were observed in the space between the two layers. The closure was withdrawn during cardiac catheterization and the boy was qualified for scheduled surgery. Currently, the boy is asymptomatic and leads a normal lifestyle.

Safety implications of concomitant administration of antidepressants and opioid analgesics in surgical patients

ABSTRACT Background Commonly prescribed antidepressants (paroxetine, fluoxetine, duloxetine, bupropion) inhibit bioconversion of several prodrug opioid medications to their active metabolite, potentially decreasing analgesic effect. There is a paucity of studies assessing the risk-benefit of concomitant administration of antidepressants and opioids. Research design and methods Observational study of adult patients taking antidepressants prior to scheduled surgery using 2017–2019 electronic medical record data to assess perioperative use of opioids and to determine the incidence and risk factors for developing postoperative delirium. We conducted a generalized linear regression with the Gamma log-link to assess the association between use of antidepressants and opioids and a logistic regression to assess the association between antidepressants use and the likelihood of developing postoperative delirium. Results After controlling for patient demographic and clinical characteristics, and postoperative pain, use of inhibiting antidepressants was associated with 1.67 times greater use of opioids per hospitalization day (p = 0.00154), a two-fold increase in the risk for developing postoperative delirium (p = 0.0224), and an estimated average of four additional days of hospitalization (p < 0.00001) compared to use of non-inhibiting antidepressants. Conclusions Careful consideration to drug-drug interactions and risk of related adverse events remains critical in the safe and optimal management of postoperative pain in patients taking concomitantly antidepressants.

Perioperative COVID-19 Screening at a Tertiary Ophthalmic Institution.

Purpose: To characterize the rate of COVID-19 positivity during presurgical screening and the surgical outcomes of ophthalmic patients who were positive for COVID-19 and to report the overall cost. Methods: This retrospective study included patients 18 years or older who had ophthalmic surgical procedures at a tertiary institution between May 11, 2020, and December 31, 2020. Patients without a valid presurgical COVID-19 test within 3 days before their scheduled procedure, who had incomplete or mislabeled visits, or who had incomplete or missing data in their file were excluded. COVID-19 screening was completed using a polymerase chain reaction (PCR) kit. Results: Of the 3585 patients who met the inclusion criteria, 2044 (57.02%) were women; the mean age was 68.2 years ± 12.8 (SD). Thirteen asymptomatic patients (0.36%) tested positive for COVID-19 via PCR screening. Three patients had a known positive COVID-19 infection within the 90 days before surgery; thus, 10 patients (0.28%) were found to have asymptomatic naïve COVID-19 infection via PCR testing. Testing was associated with a total charge of US $800 000. Five of the 13 patients (38.46%) who tested positive for COVID-19 experienced a delay in their surgery; the mean delay was 17.23 ± 22.97 days. Conclusions: Asymptomatic ophthalmic surgical patients had a low positivity rate with a limited impact on surgery scheduling at a significant cost. Further studies would be valuable in evaluating a targeted presurgical screening population as opposed to universal testing.

(Re)scheduling pollution exposure: The case of surgery schedules

Many human activities can be strategically timed around forecastable natural hazards to mute their impacts. We study air pollution shock mitigation in a high-stakes healthcare setting: hospital surgery scheduling. Using newly available inpatient surgery records from a major city in China, we track post-surgery survival for over 1 million patients, and document a significant increase of hospital mortality among those who underwent surgeries on days with high particulate matter pollution. This effect has two important features. First, pollution on the surgery day, rather than exposure prior to hospitalization, before or after the surgery, primarily explains the excess mortality. Second, a small but high-risk group – elderly patients undergoing respiratory or cancer operations – bears a majority of pollution’s damages. Based on these empirical findings, we analyze a model of hospital surgery scheduling. For over a third of the high-risk surgeries, there exists an alternative, lower-pollution day within three days such that moving the surgery may lead to a Pareto improvement in survival.11We are extremely grateful for Professor Ling Li at National School of Development, Peking University for generous help with data access. We thank Karen Brandon, Shengmao Cao, Tatyana Deryugina, Qing Gong, Elaine Hill, Wei Huang, Anupam Jena, Shanjun Li, Christopher Worsham, Yao Yao, Peng Zhang, anonymous referees, and seminar participants at the ASHEcon conference, AERE Summer Conference, Nanjing University, Shandong University, Virtual International Seminar in Environmental and Energy Economics, and Xiamen University for helpful comments. Huang acknowledges financial support from the Key Program of National Social Science Foundation of China (No. 20ZDA075). Junting Chen provided excellent research assistance. All errors are ours.

Incidence, etiology and time course of delays to adult spinal deformity surgery: a single-center experience.

We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7days of their scheduled surgery date. At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.