Surgical Research Research Articles

P590 ADVANCED-UC TRIAL: AppenDectomy Vs ANti TNF-a in inducing Clinical and EnDoscopic remission in left-sided Ulcerative Colitis – A Randomized Clinical Trial

Abstract Background A considerable amount of evidence supports the immunomodulatory role of the appendix in the development and course of Ulcerative Colitis. Indeed, the appendix could act as either a reservoir for commensal bacteria or as the "priming site” for the cytokine production and the immunological cascade triggering inflammation in the colon. Therefore a potential role of the appendix in etiopathogenesis, treatment, prophylaxis and in the colectomy rate in UC has been hypothesized. Given the lack of randomized data on the topic, the ADVANCED-UC trial aims to assess to role of appendectomy in inducing remission in refractory left sided Ulcerative Colitis. Methods Consecutive patients with left-sided UC refractory to conventional treatment and candidate to biologics will be randomized in the standard group (anti-TNF alpha) or in the intervention group (laparoscopic appendectomy). Primary endpoints: Steroid Free Clinical Remission, Endoscopic remission and Assessment of Quality of Life at 3 and 12 months. Secondary endpoints: Clinical Response, Failure Rate, Complication rate and Histological Remission at 3 and 12 months; Colectomy rate at 12, 24 and 60 months. To obtain a significance level of 5% and a test power of 90%, it is required a sample size of 148 patients (74 patients per group), assuming a 25% success rate in the control group and a 50% success rate in the experimental group. The study has been already approved by our local IRB (num. 340/21) and has been granted with the Spring Award from the Surgical Research Network by the Crohn’s and Colitis Foundation (CCF). We plan to start the enrollment in 2023 and we are currently recruiting potential participating centers, to run a multicenter, randomized controlled trial Results The findings of this study could support a change of treatment paradigm for patients refractory to conventional therapy: indeed, while an appendectomy can protect UC patients from the future use of expensive or potentially dangerous drugs, or even major surgery, the initial additional costs and potential side effects of appendectomy will be offset by substantial health gains and reduced costs later in time. On the other hand, patients undergoing appendectomy which do not experience disease remission and are forced to start biologics will be followed up for the evaluation of the colectomy rate to evaluate the possible synergic effect of appendectomy and biologics in reducing the need for total colectomy in the long term. Conclusion The aim of this study is to define the role and effects of laparoscopic appendectomy as a therapeutic option in patients with UC refractory to conventional therapy who are candidates, in the first instance, for biologic anti-TNF-a therapy.

Traci L. Hedrick, MD, MSc, FACS, FASCRS.

Dr. Traci Hedrick grew up in a small town in West Virginia prior to attending the University of Kentucky, where she earned her BS in Human Studies summa cum laude and was a member of Phi Beta Kappa. She then attended the University of Kentucky School of Medicine, receiving her M.D. in 2002. While at Kentucky, she was the top student in her class, receiving the valedictorian award and special “Best of Clerkship” awards in Anatomy, Pathology, and Surgery. Her medical school accolades also include election to junior Alpha Omega Alpha (AOA), a named scholarship, and an award from the American Medical Women's Association. Dr. Hedrick began her residency in surgery at the University of Virginia in 2002, winning the Intern of the Year Award, the Academic Achievement Award for the third-year resident with the best academic and scholarly record, the Curtis Tribble Teaching Award in 2006, and a Mulholland Teaching Award in 2007 and 2009, her Chief year. Also, during her Chief year, she won the department's award for the resident who has most contributed to the education of the junior residents (by election by the residents) and then the prestigious Association of Women Surgeons Outstanding Resident Award. Along the way, Traci also garnered several awards for her research projects conducted during 2 years of research under the direction of Dr. Robert Sawyer. Besides numerous publications, she won the Surgical Infection Society Research Training Fellowship Award and completed the requirements for a Master of Clinical Research degree.

Global geographic and gender disparities in stem cell-related surgical research: bibliometric review of the top 200 most-cited articles.

The study aimed to identify geographic and gender disparities in the quality, academic impact, and media attention of the top-cited articles related to stem cell-related surgical research. The following data was extracted for the top 200 most-cited articles (2011-2021): article- (including citation metrics and country of publication), journal- (including impact factor), and author-level (including corresponding author gender) variables. Article Altmetric Attention Score (AAS), a measure of mass mainstream and social media attention, was also recorded. Most articles originated from high-income countries (HICs: 175 [87.5%]), with only 7 (3.5%) from lower-middle-income countries. Articles from non-HIC were published in journals with significantly lower impact factors (6.66 [3.75-9.46] vs. 23.2 [7.3-32.5]; p < 0.001) and AAS (7 [3-14.5] vs. 30 [11-83]; p < 0.001). Only 44 (22%) of articles were authored by a female corresponding author, with these having significantly fewer citations than those authored by a male (289 [250-400] vs. 331.5 [267.25-451.25]; p=0.031). Even amongst the top-cited literature, our results demonstrate worrying disparities in the geographic origins of stem cell-related surgical research. The vast majority originates from HICs, with these articles being published in better journals and receiving greater media attention. We also identified significant gender disparities, with female representation being concerningly low and female-authored articles receiving significantly fewer citations.

Bibliometric Analysis of Traditional Chinese Medicine and Western Medicine in the Treatment of Obstructive Sleep Apnea Syndrome

Object: To study the research situation and direction and hot spots of Chinese and western medicine in the field of obstructive sleep apnea (OSA) in the past 36 years by bibliometrics. Methods: The paper selected the key words related to surgery streatment, continuous positive pressure ventilation (CPAP) and traditional Chinese medicine treatment to obstructive sleep apnea. The CNKI, Wanfang, VIP and sinomed databases were subject searched respectively. The publication year, journals, authors, institutions, directions and emerging hotspots were measured and visualized by vosviewer 1.6.1. Results: Over the past 36 years, the number of relevant documents has riseen, and the research scale of surgical treatment is significantly higher than that of CPAP and traditional Chinese medicine. Since 2017, the literature on surgery and CPAP treatment began to decline, and the research hotspot of traditional Chinese medicine began to rise. From the perspective of publishing journals, there are obviously more small-scale teams formed for surgical treatment research, and different teams will also form larger author cooperation teams through mutual cooperation; however, there is less cooperation between CPAP treatment and TCM treatment research teams, and research hotspots are relatively scattered. Conclusion: In recent years, the surgical treatment of OSA has begun to enter a bottleneck period. Foreign countries attach great importance to evidence-based research such as follow-up, retrospective research, prospective research, randomized controlled trials, and systematic evaluation. At present, China lacks evidence-based research with large samples and multi centers, especially based on the special growth law of children, there is a lack of follow-up research on surgical resection of children with adenoid and tonsillar hypertrophy and the treatment of OSA with Chinese medicine, acupuncture and manipulation.

Breast Surgical Oncology Epidemiologic Research: A Guide and Comparison of Four National Databases.

National databases are a rich source of epidemiologic data for breast surgical oncology research. However, these databases differ in thedemographic, surgical, and oncologic variables provided. This study aimed to compare the strengths and limitations of four national databases in the context of breast surgical oncology research. The study comprised a descriptive analysis of four national databases (the National Surgical Quality Improvement Program [NSQIP], the Nationwide Inpatient Sample [NIS], the Surveillance, Epidemiology and End Results [SEER] program, and the National Cancer Database [NCDB]) to assess their strengths and limitations in the context of breast surgical oncology. The study assessed the data available in each database for female patients with a breast cancer diagnosis between 2007 and 2017, and compared patient age, ethnicity, and race distributions. Data from 3.9 million female patients were examined, with most patients beingbetween 60 and 69 years of age, non-Hispanic, and white. Age, ethnicity, and race distributions were similar in the databases. The NSQIP includes data on operative details, comorbidities, and postoperative outcomes. The NIS provides health services and inpatient utilization information, but does not evaluate outpatient procedures. The SEER program provides population-based oncologic detail including stage, histology, and neoadjuvant/adjuvant treatment. The NCDB offers hospital-based oncologic information and the largest population in the study period, with approximately 2.5 million breast cancer patients. Epidemiologic datasets offer tremendous potential for the examination of oncologic breast surgery, with each database providing unique data useful for addressing different epidemiologic questions. Understanding the strengths and limitations of each database creates a more efficient and productive research environment.

Limitations of using the DATASUS database as a primary source of data in surgical research: a scoping review.

DATASUS is the Brazilian Public Unified Health System (SUS) department responsible for providing health data that are used as a primary source of data in several studies on surgery and surgical specialties although its main limitations have not been previously reviewed. The objective of this work is to synthesize information from studies on surgery that used DATASUS systems as a data source and to identify the main gaps in this platform. a scoping review was conducted according to the PRISMA-ScR method to identify papers on surgery, and other surgical specialties, that used the DATASUS platform as a primary data source. No restrictions were imposed regarding the type of study or year of publication. Grounded Theory was used to analyze the content of the articles. 248 works were initially analyzed and 47 were included in the final analysis of this study. The original articles included were published between 2009 and 2022 and the majority (12.76%, n=6) were published in the Journal of the Brazilian College of Surgeons. Retrospective studies (40.43%, n=19) were the most common type of study found. Content analysis of the articles identified four predominant domains in the scientific literature about the limitations of using DATASUS in surgical research: lack of data, reliability, precision and data integration. the information systems available in DATASUS are the largest source of information about the SUS, but the scientific literature on the quality of data available in these systems remains scarce and studies aimed at measuring this metric are necessary.

¿Se debería integrar la investigación en la formación del cirujano?

Surgery is an action oriented medical specialty. Training excellent surgeons requires explicit and outcome predictable educational processes, so improve educational programmes in surgery are likely to represent better health for society. Given the extraordinary scientific-technical progress achieved, numerous surgical authorities suggest that the remarkable development of surgical research it needs its integrated in the classical teaching of Surgery. Specific, it is about determining if during the period of residence the postgraduate must investigate and if this activity is assumed and undertaken, know what to research, what kind of research you should do and for how long. How to integrate research training in the context of surgical learning is still a controversial topic; however, many countries promote integration of research training during the residence period, although they are important differences of opinion in the right paper and the structure of research in surgical training. For its objetives, philosophy that sustains it and positive effects on personal scientific education, it is concluded that it is convenient and necessary to incorporate surgical research in the training curriculum of surgeons.

Limitations of using the DATASUS database as a primary source of data in surgical research: a scoping review

RESUMO Objetivo: o DATASUS é o departamento do SUS responsável por disponibilizar dados de saúde que são empregados como fonte primária de dados em diversos estudos sobre cirurgia e especialidades cirúrgicas, embora principais limitações não tenham sido revisadas anteriormente. O objetivo deste trabalho é sintetizar as informações de estudos sobre cirurgia que utilizaram sistemas do DATASUS como fonte de dados, identificando as principais lacunas. Métodos: uma revisão de escopo foi conduzida de acordo com o método PRISMA-ScR para a identificação de trabalhos sobre cirurgia, e outras especialidade cirúrgicas, que utilizaram a plataforma DATASUS como fonte primária de dados. Nenhuma restrição foi imposta em relação ao tipo de estudo ou ano de publicação. A Teoria Fundamentada em Dados foi utilizada para a análise do conteúdo dos artigos. Resultados: 248 trabalhos foram inicialmente analisados e 47 foram incluídos na análise final deste estudo. Os artigos originais incluídos foram publicados entre 2009 e 2022, maioria (12,76%, n=6) foi publicada na Revista do Colégio Brasileiro de Cirurgiões. Estudos retrospectivos (40,43%, n=19) foram o tipo de estudo mais comum encontrado. A análise dos artigos identificou quatro domínios predominantes na literatura científica acerca das limitações do uso de DATASUS em pesquisas em cirurgia: falta de dados, confiabilidade, precisão e integralização dos dados. Conclusão: os sistemas de informação dispostos no DATASUS constituem a maior fonte de informações sobre o SUS, porém a literatura científica sobre a qualidade dos dados dispostos nestes sistemas permanece escassa e trabalhos direcionados a mensurar essa métrica são necessários.

Low degree of patient involvement in contemporary surgical research: A scoping review.

Patient and public involvement in research was introduced a few decades ago. However, there is still a lack of knowledge of the degree of patient involvement, particularly in surgical research. The aim of this review was to characterize the use of patient/public involvement in contemporary surgical research and to describe how patients were involved, if they gained authorships, and which countries studies came from. In this scoping review, original studies and reviews about surgery were included that had patient/public involvement regarding study planning, conducting the study, and/or revising the manuscript. Screening was performed in the issues from 2021 of five general medicine journals with high-impact factors, also classically called "the big five," and in the ten surgical journals with the highest impact factor. Of the 808 studies, 12 studies from three journals had patient involvement, corresponding to 1.7%. Patients were involved as participants in nine of the studies either in the designing of the study and/or in revising or approving the protocol; and in four studies in revising and/or approving the manuscript. One patient fulfilled the ICMJE authorship criteria and received a group authorship. Studies with patient involvement originated from six countries namely, Australia, Canada, Netherlands, Norway, USA, and UK; with five studies from the UK. Patient involvement is very low in contemporary surgical research. It is primarily in the study planning phase, authorship is almost non-existent and few countries publish such studies.

Review of Enhanced Handheld Surgical Drills.

The handheld drill has been used as a conventional surgical tool for centuries. Alongside the recent successes of surgical robots, the development of new and enhanced medical drills has improved surgeon ability without requiring the high cost and consuming setup times that plague medical robot systems. This work provides an overview of enhanced handheld surgical drill research focusing on systems that include some form of image guidance and do not require additional hardware that physically supports or guides drilling. Drilling is reviewed by main contribution divided into audio-, visual-, or hardware-enhanced drills. A vision for future work to enhance handheld drilling systems is also discussed.

3D Printing in a hospital: Centralized clinical implementation and applications for comprehensive care.

This educational article discusses the use of 3D printing or additive manufacturing in hospitals, not just for rapid prototyping but also for creating end-use products, such as clinical, diagnostic, and educational tools. The flexibility of 3D printing is valuable for creating patient-specific medical devices, custom surgical tools, anatomical models, implants, research tools and on-demand parts, among others. The advantages of and requirements for implementing a clinical 3D printing service in a hospital environment are discussed, including centralized 3D printing management, technology, example use cases, and considerations for implementation. The article provides an overview for other institutions to reference in setting up or organizing their clinical 3D printing services and is applicable to general hospitals or various sub-specialty practices.

Preliminary results from a surgical oncology research program for medical students

Background: Medical student (MS) participation in research is variable, with the field of Surgical Oncology (SO) being no exception. Our aim was to determine a baseline for MS participation in research and knowledge in statistics of and, to describe a preliminary implementation of a MS clinical research program in SO.

Current status of health technology assessment research in Japan.

Health technology assessment (HTA) is implemented in the decision-making process for the reimbursement and pricing of drugs and medical devices around the world. This study presented the trend and characteristics of HTA research in Japan and worldwide. HTA research increased since the 2010s. Cancer was a prominent subject and the Markov model was a major analytical model in HTA research both globally and in Japan. In Japan, osteoporosis was a more popular topic, but there were fewer surgical research and review articles compared to the global trend. Since Japanese articles on HTA were much fewer than those from the United States, the United Kingdom, and China, various types of HTA research should be encouraged in Japan to promote product innovation and optimize medical expenditures.

The RAPID Consortium: A Platform for Clinical and Translational Pituitary Tumor Research.

Objectives Pituitary tumor treatment is hampered by the relative rarity of the disease, absence of a multicenter collaborative platform, and limited translational-clinical research partnerships. Prior studies offer limited insight into the formation of a multicenter consortium. Design The authors describe the establishment of a multicenter research initiative, Registry of Adenomas of the Pituitary and Related Disorders (RAPID), to encourage quality improvement and research, promote scholarship, and apply innovative solutions in outcomes research. Methods The challenges encountered during the formation of other research registries were reviewed with those lessons applied to the development of RAPID. Setting/Participants RAPID was formed by 11 academic U.S. pituitary centers. Results A Steering Committee, bylaws, data coordination center, and leadership team have been established. Clinical modules with standardized data fields for nonfunctioning adenoma, prolactinoma, acromegaly, Cushing's disease, craniopharyngioma, and Rathke's cleft cyst were created using a Health Insurance Portability and Accountability Act-compliant cloud-based platform. Currently, RAPID has received institutional review board approval at all centers, compiled retrospective data and agreements from most centers, and begun prospective data collection at one site. Existing institutional databases are being mapped to one central repository. Conclusion The RAPID consortium has laid the foundation for a multicenter collaboration to facilitate pituitary tumor and surgical research. We sought to share our experiences so that other groups also contemplating this approach may benefit. Future studies may include outcomes benchmarking, clinically annotated biobank tissue, multicenter outcomes studies, prospective intervention studies, translational research, and health economics studies focused on value-based care questions.

Clinical outcomes of the intramedullary humerus nailing system in the treatment of humerus fractures

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: After femoral and tibia bone fractures, the humerus fracture is the third long bone fracture. The purpose of this study was to clinically evaluate the outcomes of treating humerus fractures with an KN-5H humerus nailing system. The fixation of humerus fracture especially shaft fractures from intramedullay humeral nail the clinical outcomes obtained from the retrospective study of humerus nailing system on humeral fracture is controversial feature in surgical technical research, follow-up factors, and implants.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;In this retrospective study of KN-5H humerus nailing system (KN-5H intramedullary cannulated humerus nail, KN-5H reconstruction nail, cannulated and KN-5H reconstruction cannulated intramedullary humerus nail) manufactured by the Kaulmed Pvt. Ltd. is used. The total 26 patients from which 11 males and 15 females between the age group of 18-70 years with humerus fracture were taken. Patients didn't received conservative management. The fractures were categorized based on AO classification and Neer type. Th post-operative clinical effectiveness was evaluated using the Radiological evaluation, VAS score and Functional ROM results.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The mean follow-up period was 15 months (range 13 to 24 months). The mean time of union was 14 weeks (range 10 to 18 weeks) in 26 patients. No non-union occurred in any patients. Functional end results of shoulder and elbow were excellent in 92.3% patients, moderate 5.75% patients and poor in 1.95% patients. Postoperative complications included one superficial infection, 3 patients had nail impingement complain, one patient has shoulder stiffness and had pain in adduction. No implant related complication was reported.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;The treatment of proximal and diaphysis humerus fracture is highly recommended using intramedullary humeral nailing due to lower post-operative complication with high union rate. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

The role of collaboration and mentorship in the publication of surgical resident research.

Research is an integral part of surgical training and a mandated competency by national accreditation bodies. Most residents engage in research, but the conversion of this research into peer-reviewed publications is unknown. The objectives of this study were to assess the conversion rate of resident research into published manuscripts and determine what variables predict publication. Through a retrospective design, 99 resident research abstracts were identified from the Surgery Research Day at the University of Saskatchewan 2008-2018. Publication status was verified using Google Scholar and PubMed. Variables associated with resident-specific, mentor-specific, and project-specific variables were assessed for their role in predicting publication. Fifty-two (53%) of the 99 abstracts were published in a peer-reviewed journal, and 43 (43%) were presented at a national conference. Logistic regression analysis revealed multidisciplinary research (OR 4.46, CI 1.8-11.4, p = 0.002), projects involving multiple resident researchers (OR 2.56, CI 1.02-6.43, p = 0.045), and faculty supervisor having > 25 publications (OR 2.46, CI 1.03-5.88, p = 0.042) as significant predictors of publication. Our study identifies three variables related to collaboration and mentorship that can serve as potential starting points to increase research productivity amongst medical trainees.

Study management strategies to optimize student- and trainee-led collaborative research.

The collaborative research model is a powerful approach to answering surgical research questions that empowers and inspires medical students and trainees. The Opioid PrEscRiptions and usage After Surgery (OPERAS) study is a student- and trainee-led international multi-centre prospective cohort study developed in Australia and Aotearoa New Zealand. In this article, we will discuss (i) how the OPERAS study was conceptualized and structured; (ii) the channels through which information and education were communicated to collaborators; (iii) how data was stored in a secure and user-friendly fashion and (iv) the lessons learned and expected goals for the future. We aim to describe how collaborative research studies can be designed to support early career researchers to make valuable contributions to the literature.

A successful centre for translational paediatric surgical research

The National Children's Research Centre (NCRC), the single largest paediatric research centre in Ireland, has been in existence for over 50years and is located on the grounds of the largest children's hospital in Ireland; Children's Health Ireland at Crumlin. Professor Puri was appointed as the Director of the Research in 1989 and became President of the NCRC in 2009, a position he held until 2016. Professor Puri is one of the most cited paediatric surgical researchers in the world. His research work has been cited over 23,500 times in peer-reviewed articles with an h-index of 76 and i10-index of 494. The aim of this review is to analyse the most relevant areas of academic research at the NCRC, Dublin, during the years when Prof. Puri was Director/President of the NCRC. In addition, the relevant factors essential to create a successful paediatric surgical research centre will be discussed. A literature search using PubMed/Medline was carried out using the search terms "Prem Puri" over a 40-year period (1980-2020). Articles were analysed to identify the most significant research areas in the field of paediatric surgical research and the relevant laboratory and clinical findings. In addition, a separate analysis of successful funding and human factors, such as research fellows working at the NCRC, was also carried out. During the period under review, Professor Puri's team published 750 articles in peer-reviewed journals. Three main areas of research were reviewed with a total number of 391 articles: congenital diaphragmatic hernia (CDH) was the topic with the largest number of publications (153), followed by Hirschsprung's disease (HSCR) (144) and Vesicoureteral reflux (VUR) (94). Eighty research fellows, all paediatric surgeons, from 18 different countries were trained in basic science under the supervision of Professor Puri at the NCRC. Over the last three decades, the NCRC has been one of the most successful centres for paediatric surgical research in the world. The three areas of research with the largest number of publications were identified as CDH, HSCR and VUR. Various factors can explain the success of the NCRC: (a) the constant presence, for over 30years, of a very successful paediatric surgeon leading the centre, (b) a multicultural laboratory with research fellows from all over the world and (c) grants of more than 15million raised over the years, which guaranteed a constant flow of resources for laboratory research.

Barriers to and Outcomes of Initiating Clinical Research at Two Trauma Centers in Mexico

IntroductionDespite efforts to advance clinical research through collaboration between Latin and North American partners, there remains persistent barriers to performing investigative work. To overcome these obstacles, a team of over 100 surgeon-leaders from 18 Latin American countries founded the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). One of ACTUAR’s first major collaborative projects, initiated in 2018, was a prospective, observational, multicenter study evaluating quality of life after open tibia fracture management. The current study identified common barriers experienced during the initiation of this study, as exemplified through two sites in Mexico. The study aims to identify obstacles to proactively overcome these in future collaborative work. MethodsTwo research assistants from University of California, San Francisco and two research coordinators from Mexico were recruited to share their experiences, identify common barriers experienced during site enrollment and on-boarding for the ACTUAR open tibia study, and discuss possible solutions. ResultsBarriers were organized into three categories: structural, logistical, and intrapersonal. Structural barriers included differences in patient populations and resources between private and public hospitals. Logistical barriers included ambiguous ethical review processes, internet availability, and low patient follow-up. Primary enrollment as a resident responsibility led to some intrapersonal barriers. Potential solutions were identified for each barrier and agreed upon by all collaborators. ConclusionsMultiple barriers were identified by research personnel who initiated a prospective surgical clinical research study in Mexico. Through collaborative approaches, many potential solutions may help overcome these barriers and build locally led research capacity in Latin America.

Generating real-world evidence compatible with evidence from randomized controlled trials: a novel observational study design applicable to surgical transfusion research

BackgroundNumerous observational studies have revealed an increased risk of death and complications with transfusion, but this observation has not been confirmed in randomized controlled trials (RCTs). The “transfusion kills patients” paradox persists in real-world observational studies despite application of analytic methods such as propensity-score matching. We propose a new design to address this long-term existing issue, which if left unresolved, will be deleterious to the healthy generation of evidence that supports optimized transfusion practice.MethodsIn the new design, we stress three aspects for reconciling observational studies and RCTs on transfusion safety: (1) re-definition of the study population according to a stable hemoglobin range (gray zone of transfusion decision; 7.5–9.5 g/dL in this study); (2) selection of comparison groups according to a trigger value (last hemoglobin measurement before transfusion; nadir during hospital stay for control); (3) dealing with patient heterogeneity according to standardized mean difference (SMD) values. We applied the new design to hospitalized older patients (aged ≥60 years) undergoing general surgery at four academic/teaching hospitals. Four datasets were analyzed: a base population before (Base Match−) and after (Base Match+) propensity-score matching to simulate previous observational studies; a study population before (Study Match−) and after (Study Match+) propensity-score matching to demonstrate effects of our design.ResultsOf 6141 older patients, 662 (10.78%) were transfused and showed high heterogeneity compared with those not receiving transfusion, particularly regarding preoperative hemoglobin (mean: 11.0 vs. 13.5 g/dL) and intraoperative bleeding (≥500 mL: 37.9% vs. 2.1%). Patient heterogeneity was reduced with the new design; SMD of the two variables was reduced from approximately 100% (Base Match−) to 0% (Study Match+). Transfusion was related to a higher risk of death and complications in Base Match− (odds ratio [OR], 95% confidence interval [CI]: 2.68, 1.86–3.86) and Base Match+ (2.24, 1.43–3.49), but not in Study Match− (0.77, 0.32–1.86) or Study Match+ (0.66, 0.23–1.89).ConclusionsWe show how choice of study population and analysis could affect real-world study findings. Our results following the new design are in accordance with relevant RCTs, highlighting its value in accelerating the pace of transfusion evidence generation and generalization.