Surgical Categories Research Articles

Evaluation of the International Classification of Health Interventions (ICHI) in the coding of common surgical procedures.

To evaluate the International Classification of Health Interventions (ICHI) in the clinical and statistical use cases. We identified 300 most-performed surgical procedures as represented by their display names in an electronic health record. For comparison with existing coding systems, we coded the procedures in ICHI, SNOMED CT, International Classification of Diseases (ICD)-10-PCS, and CCI (Canadian Classification of Health Interventions), using postcoordination (modification of existing codes by adding other codes), when applicable. Failure analysis was done for cases where full representation was not achieved. The ICHI encoding was further evaluated for adequacy to support statistical reporting by the Organisation for Economic Co-operation and Development (OECD) and European Union (EU) categories of surgical procedures. After deduplication, 229 distinct procedures remained. Without postcoordination, ICHI achieved full representation in 52.8%. A further 19.2% could be fully represented with postcoordination. SNOMED CT was the best performing overall, with 94.3% full representation without postcoordination, and 99.6% with postcoordination. Failure analysis showed that "method" and "target" constituted most of the missing information for ICHI encoding. For all OECD/EU surgical categories, ICHI coding was adequate to support statistical reporting. One OECD/EU category ("Hip replacement, secondary") required postcoordination for correct assignment. In the clinical use case of capturing information in the electronic health record, ICHI was outperformed by the clinically oriented procedure coding systems (SNOMED CT and CCI), but was comparable to ICD-10-PCS. Postcoordination could be an effective and efficient means of improving coverage. ICHI is generally adequate for the collection of international statistics.

Perioperative sleep disturbance following mastectomy: A longitudinal investigation of the relationship to pain, opioid use, treatment, and psychosocial symptoms.

192 Background: Sleep disturbance negatively impacts quality of life and recovery. Our objective was to evaluate the relationship between individual patient factors (demographic, surgical, pain, opioid use, and psychosocial factors) and greater sleep disturbance. Methods: In this prospective longitudinal study, patients completed validated measures regarding their sleep disturbance, pain, opioid use, and psychological symptoms preoperatively and then 2 weeks, 6 and 12 months postoperatively. Objective pain sensitivity measures were evaluated at baseline using quantitative sensory testing. Univariable and multivariable generalized estimating equations (GEE) evaluated demographic, surgical, pain, and psychological predictors of sleep disturbance during the first year after surgery for breast cancer. Results: Female patients (n = 259) reported varying degrees of sleep disturbance, which were longitudinally associated with pain, psychosocial factors such as anxiety, depression, and affect. While the mean degree of sleep disturbance did not change substantially over time, the link to pain severity appeared to strengthen over the first postoperative year. Independent preoperative predictors of worse sleep disturbance on multivariable longitudinal GEE included younger age (B = -.09, p =.006), opioid use (B = 3.09, p =.02), higher pain (B =.19, p = <.001) and anxiety (B =.45, p = <.001) at baseline. On the other hand, higher basline positive affect (B = -.14, p = <.012) and the surgical category total mastectomy without reconstruction (B = -2.81, p = <.006) were indepently associated with lower sleep disturbance. Those with worse baseline sleep required more opioid analgesics during surgical recovery, and continued use of opioids at 2 weeks post-surgery was associated with disturbed sleep. Conclusions: Sleep disturbance in the first year following surgery for breast cancer varied substantially between individuals. Certain demographic, psychosocial, and pain factors explained more of this variance than surgical procedure, with the exception of total mastectomy without reconstruction that was associated with lower sleep disturbance. Sleep disturbance was associated with increased need for opioids in the perioperative period, and a propensity for more prolonged postoperative opioid use. Pre-surgical interventions in high risk individuals such as anxiety management, boosting positive affect, and controlling pain that have been shown to improve sleep quality could enhance postoperative recovery and decrease opioid use following breast surgery.

Intravascular Lithotripsy-Assisted Transfemoral TAVI: The Copenhagen Experience and Literature Review.

Transcatheter aortic valve implantation (TAVI) is currently an established therapy for elderly patients with symptomatic severe aortic valve stenosis across all surgical risk categories. Access is an important aspect when planning for and performing TAVI. The superiority of a transfemoral (TF) approach compared to a transthoracic (transapical, direct aortic) approach has been demonstrated in several studies. Recently, the introduction of intravascular lithotripsy (IVL) has made it possible to treat patients with calcified iliofemoral disease by TF approach. This article aimed to provide a comprehensive overview on the following aspects: (1) preprocedural planning for IVL-assisted TF-TAVI; (2) procedural aspects in IVL-assisted TF-TAVI; (3) outcomes of IVL-assisted TF-TAVI in an experienced TAVI center; and (4) literature review and discussion of this new emerging approach.

The Antioxidant Effect of Selenium on Succinylcholine-related Myalgia After Adult Sinuscopies: Randomized Controlled Double-Blind Trial

Succinylcholine has a fast onset, short duration of action, and is considered the choice for rapid sequence intubation. However, it produces muscle stiffness and postoperative myalgia (POM) as adverse effects. We hypothesized that the antioxidant selenium might affect POM incidence and severity. The study aimed to investigate the antioxidant effect of selenium (against free radicals' release) in minimizing the frequency of succinylcholine-related POM, measured by the 4-point myalgia score. The severity of fasciculations and the postoperative analgesic profile were recorded. The correlation between fasciculations and POM was also observed. A prospective randomized controlled double-blind clinical study. Assiut University Hospitals. The current study included 80 adult patients scheduled for sinuscopies and randomly assigned into 2 equal groups. Two hours before the induction of general anesthesia, patients in the control group received oral placebo tablets, while patients in the selenium group received oral selenium 200 µg. The primary outcome of this trial was the POM score at 24 hours. Secondary outcomes included the intensity of fasciculations, Numeric Rating Scale (NRS), rescue analgesic consumption, and adverse effects of the studied drugs. Myalgia scores were significantly decreased after selenium administration throughout the follow-up period (P = 0.023). No significant difference was reported regarding the incidence or degree of fasciculations (P = 0.511). A mild correlation was noticed between fasciculations and POM with r = 0.176 and P < 0.061. The NRS values were significant between groups at 6 hours after the procedure. There were significant differences (P < 0.05) regarding postoperative supplement analgesia, time to the first rescue analgesia, and the mean total number of analgesic claims. Significant differences were recorded for potassium levels only 30 minutes and creatine kinase levels at 6 and 24 hours postoperatively. This study was applied on a single surgical category and other types of surgical procedures may have an effect on outcomes. Additional larger sample size studies and various doses of selenium may help to validate our results. Selenium is quite a significant element of the enzymatic antioxidant process through glutathione peroxidase. We did not measure the glutathione peroxidase level in blood. Oral selenium effectively reduced the succinylcholine-induced postoperative myalgia. It prolonged the time to first required analgesia and decreased the analgesic consumption throughout the whole study period without affecting the hemodynamics or any serious adverse effects.

Surgical waste in a colorectal surgery operating room: A five-year experience

BackgroundWaste is a significant contributor to the high healthcare costs in the United States. We examined operating room waste among colorectal surgeries to determine surgical, provider or patient characteristic associations with the presence or extent of operating room waste. Additionally, we found disposable supplies (both sterile and non-sterile) to contribute to the highest proportion of waste. MethodsThis is a retrospective cross-sectional analysis of the presence and extent of operating room waste identified within the supply chain linked with the electronic medical record and administrative billing data. All inpatient and outpatient colorectal surgery patients at our institution from January 1, 2012, were included through May 31, 2017. Co-managed cases (general surgeon as primary surgeon) were excluded. Waste items included: contaminated, implanted and removed, unsatisfactory or outdated, wrongly opened, opened and unused, and items that could not be returned when the procedure or surgeon changed, or the case was canceled. Chi-square tests were used to assess risk factors associated with the presence of waste, while Kruskal-Wallis tests were used for the extent of waste (percent of supply costs). Results3297 colorectal surgery cases were performed over 5+ years. Out of those, 730 (22.1%) had a mean of 2.9 items per case identified as "wasted," representing 5.8% of all supply costs for these surgeries. The top five variables associated with waste included: surgical duration, age group of the patient, weekday surgery, surgical category, and ASA class. Surgical duration had the strongest association, followed by the patient's age group, day of surgery, surgical category, and ASA class in descending order. ConclusionsAlthough a small percentage of operative supplies are wasted in this practice, nationally, surgical waste may substantially contribute to total healthcare costs. Differences across surgeons and types of surgeries suggest that opportunities exist to reduce OR supply waste and cost.

Low Flow Nasal Cannula Versus Face Tent Use in Post-Operative Care

Background Information Understanding the effectiveness of various oxygen delivery systems in the post-anesthesia care unit (PACU) is an important prerequisite to providing safe, cost-effective, and efficient care. Two devices in particular, face tents (FTs) and low flow nasal cannulas (NCs), are often used during recovery from general anesthesia. Objectives of Project This study's aim was to determine if NCs can be used during the first 20 minutes in the PACU as an effective alternative to FT use for patients with an initial peripheral oxygen saturation (SpO2) greater than 92%. Process of Implementation A retrospective data analysis comparing the effectiveness of two oxygen delivery devices was performed using electronic health record data from 694 general anesthesia recovery encounters during a six-month period from January to June 2019. Information collected included the first five SpO2 readings in the PACU, the oxygen delivery devices used, age, gender, body mass index (BMI), type of surgery, and anesthesia type. Statement of Successful Practice For three SpO2 thresholds (>92%, >95%, and >98%), there was no difference between the NC and FT groups at 5, 10, 15, or 20 minutes after arrival in the PACU (p>0.05). Odds ratios were calculated to determine the relative influence of age and BMI on SpO2 outcomes for the FT and NC groups. Although differences were noted between groups for age and BMI, the effect size for these differences versus the overall sample was negligible (∆R2 < .003). Implications for Advancing the Practice of Perianesthesia Nursing Our results suggest that despite the higher oxygen flow rates afforded by FTs, NCs performed equally well in the immediate post-operative period. Predominant surgical categories of patients included open and laparoscopic abdominal, orthopedic, and genitourinary. The use of NCs may be desirable because of cost-effectiveness, quicker set-up time, and conservation of oxygen supplies. Understanding the effectiveness of various oxygen delivery systems in the post-anesthesia care unit (PACU) is an important prerequisite to providing safe, cost-effective, and efficient care. Two devices in particular, face tents (FTs) and low flow nasal cannulas (NCs), are often used during recovery from general anesthesia. This study's aim was to determine if NCs can be used during the first 20 minutes in the PACU as an effective alternative to FT use for patients with an initial peripheral oxygen saturation (SpO2) greater than 92%. A retrospective data analysis comparing the effectiveness of two oxygen delivery devices was performed using electronic health record data from 694 general anesthesia recovery encounters during a six-month period from January to June 2019. Information collected included the first five SpO2 readings in the PACU, the oxygen delivery devices used, age, gender, body mass index (BMI), type of surgery, and anesthesia type. For three SpO2 thresholds (>92%, >95%, and >98%), there was no difference between the NC and FT groups at 5, 10, 15, or 20 minutes after arrival in the PACU (p>0.05). Odds ratios were calculated to determine the relative influence of age and BMI on SpO2 outcomes for the FT and NC groups. Although differences were noted between groups for age and BMI, the effect size for these differences versus the overall sample was negligible (∆R2 < .003). Our results suggest that despite the higher oxygen flow rates afforded by FTs, NCs performed equally well in the immediate post-operative period. Predominant surgical categories of patients included open and laparoscopic abdominal, orthopedic, and genitourinary. The use of NCs may be desirable because of cost-effectiveness, quicker set-up time, and conservation of oxygen supplies.

The hidden burden of unplanned readmission after emergency general surgery.

There are no national studies of nonelective readmissions after emergency general surgery (EGS) diagnoses that track nonindex hospital readmission. We sought to determine the rate of overall and nonindex hospital readmissions at 30 and 90 days after discharge for EGS diagnoses, hypothesizing a significant portion would be to nonindex hospitals. The 2013 to 2014 Nationwide Readmissions Database was queried for all patients 16 years or older admitted with an EGS primary diagnosis and survived index hospitalization. Multivariable logistic regression identified risk factors for nonelective 30- and 90-day readmission to index and nonindex hospitals. Of 4,171,983 patients, 13% experienced unplanned readmission at 30 days. Of these, 21% were admitted to a nonindex hospital. By 90 days, 22% experienced an unplanned readmission, of which 23% were to a nonindex hospital. The most common reason for readmission was infection. Publicly insured or uninsured patients accounted for 67% of admissions and 77% of readmissions. Readmission predictors at 30 days included leaving against medical advice (odds ratio [OR], 2.51 [2.47-2.56]), increased length of stay (4-7 days: OR, 1.42 [1.41-1.43]; >7 days: OR, 2.04 [2.02-2.06]), Charlson Comorbidity Index ≥2 (OR, 1.72 [1.71-1.73]), public insurance (Medicare: OR, 1.45 [1.44-1.46]; Medicaid: OR, 1.38 [1.37-1.40]), EGS patients who fell into the "Other" surgical category (OR, 1.42 [1.38-1.48]), and nonroutine discharge. Risk factors for readmission remained consistent at 90 days. Given that nonindex hospital EGS readmission accounts for nearly a quarter of readmissions and often related to important benchmarks such as infection, current EGS quality metrics are inaccurate. This has implications for policy, benchmarking, and readmission reduction programs. Epidemiological study, level III.

Incidence and Recovery of Vocal Fold Immobility Following Pediatric Cardiac Operations.

Loss of laryngeal function after congenital cardiac surgery causes morbidity and prolongs hospitalization. Early diagnosis of vocal fold immobility (VFI) and referral to pediatric otolaryngology (pOTO) aids in laryngeal rehabilitation. Understanding the incidence and recovery rates of VFI enables counseling for families of infants undergoing high-risk surgery. A retrospective chart review from November 2014 to July 2019 of infants postcardiac surgery where the aortic arch or surrounding structures were manipulated and were screened via flexible fiberoptic laryngoscopy (FFL) at a single institution was performed. Patients were divided into five surgical categories: Norwood procedure, aortic arch augmentation via median sternotomy, arterial switch operation, coarctation repair via lateral thoracotomy, and cardiac surgeries including ligation of a patent ductus arteriosus (PDA). Patients undergoing isolated PDA ligation were excluded. One hundred ninety-nine qualifying operations occurred during this period; 28 patients did not undergo FFL before discharge and were excluded from the analysis. Immediately following cardiac surgery, 34% (58 of 171 patients) had VFI. Follow-up was completed by 38 of 58 patients with VFI. Complete recovery was demonstrated in 63% (24 of 38) of patients by 6 months and in 86% (33 of 38) within 18 months. The highest risk occurred with the Norwood procedure and arch augmentation via median sternotomy. Infants undergoing surgery involving the aortic arch and surrounding structures have high rates of VFI. Follow-up by pOTO is recommended to optimize laryngeal rehabilitation. Most patients have spontaneous recovery within 18 months of cardiac surgery.

Does COVID-19 Affect Survival and Functional Outcome in Emergency and Urgent Neurosurgical Procedures? A Single-Center Prospective Experience During the Pandemic

ObjectiveTo assess organizational and technical difficulties of neurosurgical procedures during the coronavirus disease 2019 (COVID-19) pandemic and their possible impact on survival and functional outcome and to evaluate virological exposure risk of medical personnel.MethodsData for all urgent surgical procedures performed in the COVID-19 operating room were prospectively collected. Preoperative and postoperative variables included demographics, pathology, Karnofsky performance status (KPS) and neurological status at admission, type and duration of surgical procedures, length of stay, postoperative KPS and functional outcome comparison, and destination at discharge. We defined 5 classes of pathologies (traumatic, oncological, vascular, infection, hydrocephalus) and 4 surgical categories (burr hole, craniotomy, cerebrospinal fluid shunting, spine surgery). Postoperative SARS-CoV-2 infection was checked in all the operators.ResultsWe identified 11 traumatic cases (44%), 4 infections (16%), 6 vascular events (24%), 2 hydrocephalus conditions (8%), and 2 oncological cases (8%). Surgical procedures included 11 burr holes (44%), 7 craniotomies (28%), 6 cerebrospinal fluid shunts (24%), and 1 spine surgery (4%). Mean patient age was 57.8 years. The most frequent clinical presentation was coma (44 cases). Mean KPS score at admission was 20 ± 10, mean surgery duration was 85 ± 63 minutes, and mean length of stay was 27 ± 12 days. Mean KPS score at discharge was 35 ± 25. Outcome comparison showed improvement in 16 patients. Four patients died. Mean follow-up was 6 ± 3 months. None of the operators developed postoperative SARS-CoV-2 infection.ConclusionsStandardized protocols are mandatory to guarantee a high standard of care for emergency and urgent surgeries during the COVID-19 pandemic. Personal protective equipment affects maneuverability, dexterity, and duration of interventions without affecting survival and functional outcome.

Laparotomic versus robotic surgery in elderly patients with endometrial cancer: A systematic review and meta-analysis.

BackgroundAlthough robotics has been shown to improve outcomes in some high‐difficulty surgical category patients, it is unclear if such an approach may improve outcomes in elderly patients with endometrial carcinoma (EC).ObjectiveTo compare robotic and laparotomic surgery in the treatment and staging of elderly EC patients.Materials and methodsA systematic review and meta‐analysis was performed assessing the risk of overall, intra‐operative, and peri‐operative complications associated with the surgical approach (laparotomic vs robotic) for elderly patients with EC by relative risk (RR). Pooled means ± standard deviation of length of stay were compared with the unpaired t test. Subgroup analyses for overall complications were performed based on different age cut‐offs (>70, >65, and >75 years) and severity of complications (minor and major). A value of P less than 0.05 was considered significant.ResultsFive studies with 7629 EC patients were included. Pooled RR for robotic compared with laparotomic surgery was 0.40 (P < 0.001) for overall, 0.46 (P = 0.18) for intra‐operative, and 0.43 (P < 0.001) for peri‐operative complications. Pooled difference between means ± standard deviation of length of stay for robotic versus laparotomic surgery was −3.34 (P < 0.001). At subgroup analyses, pooled RR of overall complications for robotic surgery versus laparotomic surgery was 0.34 (P < 0.001) in the >70 years, 0.51 (P < 0.01) in the >65 years, 0.20 (P = 0.12) in the >75 years groups. Pooled RR was 0.50 (P = 0.1) in the minor complications subgroup, and 0.42 (P = 0.002) in the major complications subgroup.ConclusionRobotics might be a viable alternative to the laparotomic approach for EC in elderly patients because it significantly decreases the risk of overall and peri‐operative complications (mainly major complications), and the length of stay when compared with laparotomy. The decrease in risk of overall complications is greater with increasing patient age.

Contemporary practice patterns of transurethral therapies for benign prostate hypertrophy: results of a worldwide survey.

To perform a global survey to identify contemporary practice patterns of transurethral therapies for benign prostatic hypertrophy. A REDCap survey was distributed to the ~ 3500 members of the Endourological Society. Surgeons completed demographic information and then selected the BPH therapies they perform 10 cases/year. There were four categories of BPH therapies: ablation, enucleation, resection/vaporization, and MIST (minimally invasive surgical technique). Within each category, there were subcategories to account for different energy modalities. All statistical analyses were performed using SAS 9.4. A total of 175 surgeons responded to our survey. Prostate resection/vaporization remained the most commonly utilized technique (51.9%, n = 147/283) followed by enucleation (22.6%, n = 64/283). Bipolar TURP (bTURP) was the most common modality for prostate resection (69.4%, n = 102/147). Holmium laser enucleation (HoLEP) was the most common modality for enucleation (46.9%, n = 30/64). Urolift® was performed more often than Rezūm™ (55.9% vs. 44.1%, n = 19/34 vs. 15/34, respectively). Among surgeons performing ablation, country of practice was a significantly associated with length of stay (LOS), p < 0.0001. For surgeons performing enucleation, academic institution and completion of a fellowship were associated with postoperative day (POD) 1 catheter removal (p = 0.0240 and p = 0.020, respectively). In this contemporary, global survey of the Endourology Society, resection/vaporization techniques were the most commonly performed. Rates of MISTs remained relatively low at 12.1%. Academic institution and fellowship status were associated with shorter catheterization times and LOS for certain surgical categories.

A comparison of two different refeeding protocols and its effect on hand grip strength and refeeding syndrome: a randomized controlled clinical trial.

Optimal refeeding protocols in older malnourished hospital patients remain unclear. We aimed to compare the effect of two different refeeding protocols; an assertive and a cautious protocol, on HGS, mortality and refeeding syndrome (RFS), in patients ≥ 65years METHODS: Patients admitted under medical or surgical category and at risk of RFS, were randomized to either an enteral nutrition (EN) refeeding protocol of 20kcal/kg/day, reaching energy goals within 3days (intervention group), or a protocol of 10kcal/kg/day, reaching goals within 7days (control group). Primary outcome was the difference in hand grip strength (HGS) at 3months follow-up, in an intention to treat analysis. RFS (phosphate < 0.65mmol/L) during the hospital stay and mortality rates at 3months were secondary outcomes. A total of 85 patients were enrolled, with mean (SD) age of 79.8(7.4) and 54.1% female, 41 in the intervention group and 44 in the control group. HGS was similar at 3months with mean change of 0.42kg (95% CI -2.52 to 3.36, p = 0.78). Serum phosphate < 0.65mmol/L was seen in 17.1% in the intervention group and 9.3% in the control group, p = 0.29. There was no difference in mortality rates (39% vs 34.1%, p = 0.64). An indication of more respiratory distress was found in the intervention group, 53.6% vs 30.2%, p = 0.029. A more assertive refeeding protocol providing 20kcal/kg/day did not result in improved HGS measured 3months after discharge compared with a cautious refeeding (10kcal/kg/day) protocol. No difference in incidence of mortality or RFS was found. ClinicalTrials.gov Protocol Record 2017/FO148295, Registered:21st of February, 2017.

The impact of delayed management of fall-related hip fracture management on health outcomes for African American older adults.

Black hip fracture patients experience worse health outcomes than otherwise similar White patients, but causes of these disparities are not known. We sought to determine if delays in hip fracture surgery and/or hospital structures contribute to racial disparities in hip fracture outcomes. Using 2006 to 2016 Trauma Quality Program Public Use Files, we identified hip fracture patients with primary mechanisms of fall from standing and determined surgical treatment category (no surgery, surgery within 24 hours after arrival, surgery 24-48 hours after arrival, surgery more than 48 hours after arrival) as well as hospital structure characteristics (trauma center designation, teaching status, profit status, bed size). We used generalized structural equation models to conduct path analyses and determine if hip fracture treatment and hospital characteristics mediated the relationship between race (non-Hispanic Black/non-Hispanic White) and outcomes (complications, length of stay, disposition). Non-Hispanic Black patients were more likely than non-Hispanic White patients to receive treatment at an academic medical center (49.1% vs. 28.0%), at a hospital with >600 inpatient beds (39.5% vs. 25.3%), and at a level I or II trauma center (86.8% vs. 77.7%); were more likely to go without hip fracture repair surgery (22.8% vs. 21.4%); and were more likely to have delayed surgery >48 hours after hospital arrival (15.5% vs. 10.6%). Path analysis suggests hip fracture treatment group and hospital characteristics mediate the relationship with complications, length of stay, and disposition. Non-Hispanic Black patients with fall-related hip fracture are more likely to experience delays in care, complications, and longer inpatient stays. Hospital characteristics contribute to increased risk of complications and longer length of stay, both as independent determinants of outcomes and as determinants of delays in hip fracture surgery. Prognostic and epidemiologic, level III.

Parallelism in Autonomous Robotic Surgery

Robots can perform multiple tasks in parallel. This work is about leveraging this capability in automating multilateral surgical subtasks. In particular, we explore, in a simulation study, the benefits of considering this parallelism capability in developing execution models for autonomous robotic surgery. We apply our work to two surgical subtask categories: (i) coupled-motion subtasks, where multiple robot arms share the same resources to perform the subtask, and (ii) decoupled-motion subtasks, where each robot arm executes its part of the task independently from the others. We propose and develop parallel execution models for the surgical debridement subtask, a representative of the first category, and the multi-throw suturing subtask, a representative of the second one. Comparing these parallel execution models to the state-of-the-art ones shows significant reductions in the subtasks completion time by at least 40%. In 20 trials, our results show that our proposed model for the surgical debridement subtask, that uses hierarchical concurrent state machines, provides a parallel execution framework that is efficient while greatly reducing collisions between the arms compared to a naive parallel execution model without coordination. We also show how applying parallelism can lead to execution models that go beyond the normal practice of human surgeons. We finally propose the notion of “automation for surgical manual execution” where we argue that autonomous robotic surgery research can be used as a tool for surgeons to discover novel manual execution models that can significantly improve their surgical practice.

A Scoping Review of Pharmacotherapy, Complementary, and Alternative Medicine (CAM), and Surgical Therapies for Androgenic Alopecia

Androgenic alopecia (AGA) is the most common form of non-scarring alopecia, affecting millions of men and women in the United States (U.S.). This review highlights alternative and complementary treatment options for AGA. The treatment regimens for AGA have increased in pharmacotherapeutics, surgical, and complementary (CAM) categories. Each of the different treatment approaches can now be utilized by dermatologists to combat patient hair loss. The U.S. Food and Drug Administration (FDA) has approved only two agents to treat AGA: prescription-only, oral finasteride and over-the-counter (OTC), topical minoxidil. Increased availability of therapies claiming hair regrowth properties, coupled with limited pharmacotherapeutic options for AGA, lead patients to seek alternative treatments. Increased awareness of the current evidence supporting complementary and alternative therapies among dermatologists will facilitate appropriate and timely education of AGA patients.

Short-term Effects of Canceled Elective Procedures Due to COVID-19: Evidence From the Veterans Affairs Healthcare System.

To determine whether delayed or canceled elective procedures due to COVID-19 resulted in higher rates of ED utilization and/or increased mortality. On March 15, 2020, the VA issued a nationwide order to temporarily pause elective cases due to COVID-19. The effects of this disruption on patient outcomes are not yet known. This retrospective cohort study used data from the VA Corporate Data Warehouse. Surgical procedures canceled due to COVID-19 in 2020 (n = 3326) were matched to similar completed procedures in 2018 (n = 151,863) and 2019 (n = 146,582). Outcome measures included 30- and 90-day VA ED use and mortality in the period following the completed or canceled procedure. We used exact matching on surgical procedure category and nearest neighbor matching on patient characteristics, procedure year, and facility. Patients with elective surgical procedures canceled due to COVID-19 were no more likely to have an ED visit in the 30- [Difference: -4.3% pts; 95% confidence interval (CI): -0.078, -0.007] and 90 days (-0.9% pts; 95% CI: -0.068, 0.05) following the expected case date. Patients with cancellations had no difference in 30- (Difference: 0.1% pts; 95% CI: -0.008, 0.01) and 90-day (Difference: -0.4% pts; 95% CI: -0.016, 0.009) mortality rates when compared to similar patients with similar procedures that were completed in previous years. The pause in elective surgical cases was not associated with short-term adverse outcomes in VA hospitals, suggesting appropriate surgical case triage and management. Further study will be essential to determine if the delayed cases were associated with longer-term effects.

Postoperative infection and mortality following elective surgery in the International Surgical Outcomes Study (ISOS).

Postoperative infection is one of the most frequent and important complications after surgery. The epidemiology of infection following elective surgery remains poorly described. This was a prospective analysis of the International Surgical Outcomes Study (ISOS) describing infection by 30 days after elective surgery. Associations between postoperative infection (primary outcome) and baseline demographic, surgical, and anaesthetic risk factors were assessed. Analyses were carried out using logistic and linear regression models. Secondary outcomes were 30-day mortality and duration of hospital stay. Treatments received by patients after different types of infection were evaluated. Some 44814 patients were included in the analysis, with a total of 4032 infections occurring in 2927 patients (6.5 per cent). Overall, 206 patients died, of whom 99 of 2927 (3.4 per cent) had infection. Some 737 of 4032 infections (18.3 per cent) were severe; the most frequent types were superficial surgical-site infection (1320, 32.7 per cent), pneumonia (708, 17.6 per cent), and urinary tract infection (681, 16.9 per cent). Excluding missing data, antimicrobials were used in 2126 of 2749 infections (77.3 per cent), and 522 of 2164 patients (24.1 per cent) required admission to critical care. Factors associated with an increased incidence of infection in adjusted analyses were: age, male sex, ASA grade, co-morbid disease, preoperative anaemia, anaesthetic technique, surgical category, surgical severity, and cancer surgery. Infection significantly increased the risk of death (odds ratio 4.68, 95 per cent c.i. 3.39 to 6.47; P < 0.001), and duration of hospital stay by on average 6.45 (6.23 to 6.66) days (P < 0.001). Infection is a common complication after elective surgery. Recognition of modifiable risk factors will help inform appropriate prevention strategies.

Does povidone-iodine application in surgical procedures help in the prevention of surgical site infections? An updated meta-analysis.

IntroductionSurgical site infections (SSIs) occur after an operative procedure and can range from superficial to deep wound infections. The World Health Organization (WHO) and the Centers for Disease Control (CDC) have proposed guidelines recommending measures to prevent SSIs. Intraoperative measures are largely focused on decontamination of the skin and intraoperative wound irrigation using soap and antiseptics and are simple, efficient, and cost-effective measures to reduce SSIs. Povidone-iodine (PVI) is a topical antiseptic widely used for the reduction of SSIs.AimA meta-analysis was conducted to determine the efficacy of preoperative or intraoperative use of PVI from randomized controlled trials (RCTs).Material and methodsA systematic literature review was conducted using MEDLINE and Central databases for RCTs that involved PVI application versus saline or no treatment control groups across various surgical categories. The primary outcome was SSI or post-operative wound infections. A random-effects model was used to calculate the pooled risk ratio and subgroup analyses were performed.ResultsA total of 59 RCTs were included in the meta-analysis with information from 20,497 patients. A reduction in overall SSI incidence was found (RR = 0.70, 0.60–0.80, p = 0.0002, I2 = 44%). Subgroup analyses showed that the comparator treatment and type of procedure did not modify the effect of PVI on SSI incidence. However, inconsistent results on SSI incidence were obtained when the data were stratified by PVI application method and surgery category.ConclusionsThe results of the meta-analysis provide support for the preoperative or intraoperative use of PVI in decreasing the incidence of SSI.

Reintervention with Transcatheter and Surgical Aortic Valves: A Systematic Review and Meta-Analysis

Background: Despite expanding indications, data regarding the long-term durability of transcatheter heart valves (THV) are limited. Methods: We performed a systematic review and meta-analysis of all published studies with ≥5years of follow-up reporting aortic valve reintervention rates of transcatheter (TAVR) and surgical aortic valve replacement (SAVR). Randomized controlled trials (n = 4) and propensity-matched observational studies (n = 1) involving all surgical risk categories were included. The primary endpoint was the composite of aortic valve reintervention and death. Results: The meta- analysis included 4145 patients: 2101 underwent TAVR (mean age 81.7 ± 6.7 years, 54% male) and 2044 SAVR (mean age 81.8 ± 6.6 years, 54% male). All TAVR procedures were performed with early generations of THV. At a median follow-up of 5 years (range 5 - 6 years), TAVR had higher reintervention rates (odds ratio (OR) 3.33; 95% CI: [1.78, 6.24], p 2 = 0%), all-cause mortality (OR 1.45; 95% CI: [1.22, 1.75], p 2 = 44%) and the composite of reintervention and death (OR 1.47; 95% CI: [1.14, 1.91], p 2 = 64%). Rates of myocardial infarction, transient ischemic attack, stroke, endocarditis, and the composite of endocarditis and thrombosis were similar between the groups. Conclusion: Despite comparable short and medium-term results, TAVR with early-generation THV has higher rates of reintervention and the composite of reintervention and death. Further studies employing newer definitions of structural valve deterioration and bioprosthetic valve failure are needed to assess whether technological enhancements in THV technology will improve long-term outcomes.

A Review of Orthopaedic Resident Case Logs to Identify Fluctuations in Exposure to Adult Orthopaedic Procedures.

Introduction:Orthopaedic surgery resident case exposure is an important component of surgical training and is monitored by the Accreditation Council for Graduate Medical Education (ACGME) to ensure resident readiness for graduation. The purpose of this study was to investigate trends in exposure to adult orthopaedic surgical procedures and analyze the impact of the 2013 update in ACGME case logging expectations.Methods:A retrospective review of ACGME case log data was conducted for adult orthopaedic procedures performed by graduating orthopaedic surgery residents from 2012 to 2020. Trends in the number of cases logged and the case share by anatomical location were investigated. Linear regression analysis was performed to analyze changes in case number over the 9-year period.Results:For all surgical categories, there was stability in the average case number per resident from 2012 to 2013, followed by a precipitous decrease from 2013 to 2014. From 2014 to 2020, there has been a gradual increase in case number for all categories except “other musculoskeletal (MSK),” resulting in a total 46% recovery since the 2014 decline. Concomitant with the decline, there was a relative increase in pelvis/hip and femur/knee procedures and decrease in shoulder, other MSK, and spine procedures. From 2014 to 2020, shoulder, humerus/elbow, pelvis/hip, leg/ankle, foot/toes, and spine cases have gradually accounted for a larger proportion of total cases while femur/knee and “other MSK” cases have accounted for less.Conclusions:The 2013 update in ACGME case logging expectations was associated with a significant decrease in case number. This is likely a reflection of residents correctly entering 1 primary Current Procedural Terminology code for each surgical case. Programs should be aware of a general increase in case number since 2014 and acknowledge the fact that some procedure types may be given priority from a logging standpoint when multiple Current Procedural Terminology codes apply.