Surgical Subgroups Research Articles

Sustained Performance of Cardiac Arrest Prevention in Pediatric Cardiac Intensive Care Units.

The Pediatric Cardiac Critical Care Consortium (PC4) cardiac arrest prevention (CAP) quality improvement (QI) project facilitated a decreased in-hospital cardiac arrest (IHCA) incidence rate across multiple hospitals. The sustainability of this outcome has not been determined. To examine the IHCA incidence rate at participating hospitals after the QI project ended and discern which factors best aligned with sustained improvement. This observational cohort study compared IHCA data from the CAP era (July 1, 2018, to December 31, 2019) with data from the 2-year follow-up era (March 1, 2020, to February 28, 2022). Data were obtained from pediatric cardiac intensive care units (CICUs) from 17 PC4 CAP-participating hospitals. The CAP practice bundle was designed to facilitate local practice integration, with the intention to implement, adapt, and continue CAP processes beyond the CAP era. A web-based survey was administered 2 years after the end of the project to estimate CAP-specific QI work. Risk-adjusted IHCA incidence rates across all admissions were compared between study eras. The survey generated a novel hospital-specific QI sustainability score, which is generally reflective of the sum of local CAP work performed. There were no clinically important differences in demographic and admission characteristics between the 13 082 CAP era admissions and 16 284 follow-up admissions (total mean [SD] age, 5.1 [8.4] years; 56.1% male). Risk-adjusted IHCA incidences were not different between the CAP vs follow-up eras (2.8% vs 2.8%; odds ratio, 1.03; 95% CI, 0.89-1.19), suggesting sustained prevention improvement. There was also no difference between eras in risk-adjusted IHCA incidence within medical, surgical, or high-risk subgroups. A lower hospital QI sustainability score was correlated with higher odds for IHCA in the follow-up vs CAP era (correlation coefficient, -0.58; P = .02). Five hospitals had increases of 1% or greater in risk-adjusted IHCA rates in the follow-up era; these hospitals had significantly lower QI sustainability scores and were less likely to have adopted sustainability elements during the CAP era or report persistent engagement for CAP-related QI processes during follow-up. In this cohort study of all CICU admissions across 17 hospitals, IHCA prevention was feasible and sustainable; the established reduction in risk-adjusted IHCA rate was maintained for at least 2 years after the end of the CAP project. Both implementation strategies and continued engagement in CAP processes during the follow-up era were associated with sustained improvement.

The STS 2024 Risk Models for Lung Cancer Resection: Continued Refinement and Improved Outcomes

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTSD) has been used to develop risk models for patients undergoing pulmonary resection for cancer. Leveraging a contemporary and more inclusive cohort, we sought to refine these models. The study population consisted of adult patients in the STS GTSD who underwent pulmonary resection for cancer between 2015 and 2022. Unlike previous models, non-elective operations were included. Separate risk models were derived for operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used with predictors retained in models if p<0.10. All derived models were validated using 9-fold cross validation. Model discrimination and calibration were assessed for the overall cohort and for surgical procedure, demographic, and risk factor subgroups. Data from 140,927 patients at 337 participating centers were included in the study. Overall operative mortality rate was 1.1%, major morbidity 7.3%, and composite morbidity or mortality 7.6%. Novel predictors of short-term outcomes included interstitial lung disease, DLCO, and payor status. Overall discrimination was superior to previous STS pulmonary resection models for operative mortality [C-statistic = 0.80] and for composite morbidity or mortality [C-statistic = 0.70]. Model discrimination was comparable and model calibration was excellent across all procedure- and demographic-specific sub-cohorts. Among STS GTSD participants, major morbidity and operative mortality rates remain low following pulmonary resection. The newly derived pulmonary resection risk models demonstrate superior performance compared to previous models, with broader real-life applicability and clinical face validity.

54P Real-world data of patients with recurrent BRCA-mutated platinum-sensitive ovarian cancer treated with olaparib maintenance: Surgical outcome subgroup analysis from the C-PATROL study

54P Real-world data of patients with recurrent BRCA-mutated platinum-sensitive ovarian cancer treated with olaparib maintenance: Surgical outcome subgroup analysis from the C-PATROL study

Orbital subperiosteal abscess in adolescents and adults: predictors and outcomes of nonsurgical management and surgical approaches

ABSTRACT Purpose The aim of this study was to assess predictors and outcomes of subperiosteal abscess (SPA) management in adolescents and adults at two tertiary care centers. Methods This retrospective cohort study included cases of SPA from January 1 2000 to October 9 2022 at two institutions. Patients 9 years or older were categorized into surgical and nonsurgical cohorts. Surgical subgroups included those who underwent functional endoscopic sinus surgery (FESS) alone, external (transcutaneous or transconjunctival) orbitotomy alone, or combined FESS and external surgery. The presented features were assessed as potential treatment predictors. Outcomes included length of stay (LOS), final best-corrected visual acuity (BCVA), readmission rate, and reoperation rate. Results Of the 159 SPA cases included, 127 (79.9%) underwent surgery and 32 (20.1%) were managed nonsurgically. The nonsurgical cohort was younger (p = .003) with smaller abscesses (p < .001) that were more likely to be medial (p < .001). The nonsurgical cohort had shorter LOS (p < .001); final BCVA and readmission rates were similarly favorable. Abscess location was correlated with surgical approach. Superior SPA that underwent FESS or external surgery alone had higher reoperation rates (57.1.0% and 58.3%, respectively) than combined (17.9%). External approach and FESS alone resulted in lower reoperation rates (15.4% and 15.0%, respectively) than combined (27.3%) for medial SPA. Subgroup analysis in the sinusitis cohort yielded similar results. Conclusions A trial of nonsurgical management may be safe and effective for select patients aged 9 years and older with sinusitis-derived, medial, and small SPA. When surgery is indicated, approach should be guided by abscess location to minimize reoperation risk.

Preoperative peripheral inflammatory markers are predictors of postoperative central diabetes insipidus in craniopharyngioma patients: a retrospective study

BackgroundPostoperative central diabetes insipidus (CDI) is commonly observed in craniopharyngioma (CP) patients, and the inflammatory response plays an important role in CPs. We aimed to evaluate the predictive value of preoperative peripheral inflammatory markers and their combinations regarding CDI occurrence in CPs.MethodsThe clinical data including preoperative peripheral inflammatory markers of 208 CP patients who underwent surgical treatment were retrospectively collected and analyzed. The preoperative peripheral white blood cells (WBC), neutrophils, lymphocytes, monocytes, platelet (PLT), neutrophil-to-lymphocyte ratio (NLR), derived-NLR (dNLR), monocyte-to-lymphocyte ratio (MLR) and PLT-to-lymphocyte ratio (PLR) were assessed in total 208 CP patients and different age and surgical approach CP patient subgroups. Their predictive values were evaluated by the receiver operator characteristic curve analysis.ResultsPreoperative peripheral WBC, neutrophils, NLR, dNLR, MLR, and PLR were positively correlated and lymphocyte was negatively associated with postoperative CDI occurrence in CP patients, especially when WBC ≥ 6.66 × 109/L or lymphocyte ≤ 1.86 × 109/L. Meanwhile, multiple logistic regression analysis showed that WBC > 6.39 × 109/L in the > 18 yrs age patients, WBC > 6.88 × 109/L or lymphocytes ≤ 1.85 × 109/L in the transcranial approach patients were closely associated with the elevated incidence of postoperative CDI. Furthermore, the area under the curve obtained from the receiver operator characteristic curve analysis showed that the best predictors of inflammatory markers were the NLR in total CP patients, the MLR in the ≤ 18 yrs age group and the transsphenoidal group, the NLR in the > 18 yrs age group and the dNLR in the transcranial group. Notably, the combination index NLR + dNLR demonstrated the most valuable predictor in all groups.ConclusionsPreoperative peripheral inflammatory markers, especially WBC, lymphocytes and NLR + dNLR, are promising predictors of postoperative CDI in CPs.

The Impact of the Novel Coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Case Fatality Rates and Cost of Surgical Care in Brazil.

Background The coronavirus disease 2019 (COVID-19) pandemic provoked disruptions in healthcare delivery. Following the recommendations of major surgical societies and surgical departments globally, most surgeries were widely canceled or postponed, causing significant disruptions to healthcare delivery worldwide, including in Brazil. Brazil's public healthcare system - Sistema Único de Saúde (SUS) was particularly affected, with a substantial decline in elective procedures, especially during the pandemic's early stages. The impact of the pandemic on surgical services in Brazil has not been adequately studied since most studies only cover the early phases of the pandemic. Thus, this study aims to analyze the case fatality rates and costs, associated with the different surgical procedure subgroups performed during the pre-pandemic, pandemic, recovery, and post-pandemic periods in all five regions of Brazil. Methods A retrospective cross-sectional design was used to examine surgical cases from 2019 to 2022. Data was divided into four time periods, named as the pre-pandemic (March-December 2019), pandemic (March-December 2020), recovery (March-December 2021), and post-pandemic (March-December 2022), and was analyzed for the cost of surgical procedures in the aforementioned four periods. In addition, the case fatality rates and rate ratios in the four periods stratified according to region were calculated. Results The cost of surgical procedures decreased during the pandemic and recovery period compared with pre-pandemic for all procedures except thoracic surgery where it was higher in the recovery period than pre-pandemic. No statistically significant change in cost was observed in surgeries of the central and peripheral nervous system, circulatory system, obstetric, and oncology. Case fatality rates increased among all five regions of Brazil in pandemic and recovery periods compared to pre-pandemic and post-pandemic periods. Case fatality rates increased during the pandemic and/or recovery as compared to pre-pandemic in all procedures except visual apparatus and obstetric surgeries were not affected by the pandemic in terms of case fatality rates. Conclusion The COVID-19 pandemic had a significant impact on surgical care costs and case fatality rates for surgery in Brazil. There was a decreasing trend in the costs of procedures during the pandemic, followed by a gradual recovery to baseline values, except for thoracic surgery. Case fatality rates rose initially and then declined, ultimately reaching baseline levels. The pandemic posed significant challenges to the healthcare system, affecting medical services, including surgical care.

Curative effect analysis of robot-assisted drainage surgery in treatment of spontaneous hypertensive brainstem hemorrhage.

Spontaneous hypertensive brainstem hemorrhage (HBSH) is characterized by sudden onset, rapid progression and poor prognosis. There has been a growing tendency of surgical treatment for HBSH. This study aimed to investigate outcomes and potential factors associated with the prognosis of robot-assisted drainage surgery for HBSH treatment. Patients with HBSH from July 2016 to March 2023 at a single neurosurgery center were included and divided into conservative group and surgical groups. Baseline and clinical data, radiographic characteristics, complications, and outcome evaluations were recorded and analyzed. A total of 125 patients, with 74 in the conservative group and 51 in the surgical group, were enrolled in the study. Mortality at 6 months was 59/74 (79.7%) in the conservative group and 9/51 (17.6%) in the surgical group. Twenty-four patients (47.1%) achieved favorable outcomes in the surgical group, whereas this rate in the conservative group was only 5.4% (4/74). There was a significant difference in NIHSS, GCS, and mRS at 6 months between surviving patients in the conservative and surgical groups. In prognostic analysis in the surgical subgroup, initial GCS score [5 (IQR 4-7) vs. 3 (IQR 3-4), p < 0.001], NIHSS [36 (IQR 32-38) vs. 40 (IQR 38-40), p < 0.001], smoking history [45.8% (11/24) vs. 74.1% (20/27), p = 0.039], hematoma volume [6.9 (IQR 6.2-7.6) vs. 9.6 (IQR 7.3-11.4), p = 0.001], and hemorrhage location (p = 0.001) were potential risk factors for poor 6-month prognosis after robot-assisted surgery for HBSH. Based on the results of this study, robot-assisted minimally invasive drainage of brain stem hematoma may significantly reduce mortality and improve prognosis. Surgery should be conducted for selected patients.

Gross total resection and survival outcomes in elderly patients with spinal chordoma: a SEER-based analysis.

The association between aggressive resection and improved survival for adult spinal chordoma patients has not been well characterized in the geriatric population. Thus, the present study aimed to elucidate the relationship between gross total resection (GTR) and survival outcomes for patients across different age groups. The authors isolated all adult patients diagnosed with spinal chordoma from the 2000-2019 Surveillance, Epidemiology, and End Results database and divided patients into three surgical subgroups: no surgery, subtotal resection (STR), and GTR. Kaplan-Meier curves with a log-rank test were used to discern differences in overall survival (OS) between surgical subgroups. Univariate and multivariate analyses were used to identify prognostic factors of mortality. There were 771 eligible patients: 227 (29.4%) received no surgery, 267 (34.6%) received STR, and 277 (35.9%) received GTR. Patients receiving no surgery had the lowest 5-year OS (45.2%), 10-year OS (17.6%), and mean OS (72.1 months). After stratifying patients by age, our multivariate analysis demonstrated that patients receiving GTR aged 40-59 (HR=0.26, CI=0.12-0.55, p<0.001), 60-79 (HR=0.51, CI=0.32-0.82, p=0.005), and 80-99 (HR=0.14, CI=0.05-0.37, p<0.001) had a lower risk of mortality compared to patients undergoing no surgery. The frequency of receiving GTR also decreased as a function of age (16.4% [80-99 years] vs. 43.2% [20-39 years]; p<0.001), but the frequency of receiving radiotherapy was comparable across all age groups (48.3% [80-99 years] vs. 45.5% [20-39 years]; p=0.762). GTR is associated with improved survival for middle-aged and elderly patients with spinal chordoma. Therefore, patients should not be excluded from aggressive resection on the basis of age alone. Rather, the decision to pursue surgery should be decided on an individual basis.

Thromboembolic and bleeding events after valvular intervention in patients with atrial fibrillation

AimTo assess outcomes after cardiac surgery with biological valve replacement, valve repair or transcatheter aortic valve implantation (TAVI) in patients with atrial fibrillation (AF) in accordance with oral anticoagulant (OAC)...

Impact of the COVID-19 pandemic on ophthalmic surgery at a tertiary hospital in South Africa

Background: The coronavirus disease 2019 (COVID-19) pandemic impacted the provision of ophthalmic care.Aim: This study aimed to quantify the pandemic on the number of ophthalmic surgeries.Setting: The study was conducted at a South African tertiary academic hospital.Methods: A retrospective comparative analysis of eye surgeries 1 year pre- and post- onset of the COVID-19 lockdown (27 March 2019 to 26 March 2021) was conducted. Theatre surgical records were analysed 1-year pre- and post-lockdown. All surgical procedures were recorded and subcategorised into cataract, cornea, glaucoma, oncologic, orbital, oculoplastic, strabismus, trauma, vitreoretinal, and other. Trauma surgeries in the post-pandemic year were sub-analysed based on the level alcohol restriction level.Results: Total surgeries decreased from 3521 to 1551 (P 0.001). Using multivariate analysis, the incidence rate ratio (IRR) for all surgeries during the pandemic was 0.47 (P 0.001) with a significantly reduced IRR during the first wave of 0.427 (P = 0.003) and a non-significant change during wave two; IRR 1.25 (P = 0.36). All surgical subgroups decreased significantly except oncology, insignificant decrease from 211 to 180 (P = 0.12). Trauma significantly decreased during periods of total alcohol bans; IRR of 0.50 (P 0.001). An insignificant decrease was found during periods of partial ban with an IRR of 0.83 (P = 0.06) compared with periods without alcohol restrictions.Conclusion: Post lockdown, the total number of surgeries decreased in all subgroups except oncology. Alcohol bans significantly decreased trauma surgeries.Contribution: This article provides valuable insight, which may inform public health policy.

Clinical characteristics and prognosis of early-onset cholangiocarcinoma: a population-based study

Background Little is known about the disease of early-onset cholangiocarcinoma (EOC). The primary objective of this study was to compare EOC with later-onset cholangiocarcinoma (LOC) concerning clinical features and survival prognosis. Methods 19325 cholangiocarcinoma patients were extracted from 1975 to 2020 in the SEER database. Cox regression analysis and Kaplan-Meier survival curves were used for the evaluation of cause-specific survival (CSS) and overall survival (OS). To reduce confounding, we compared survival differences between the EOC and LOC groups using propensity score matching (PSM). Results 4037 cholangiocarcinoma patients were included in the study, of which 274 were EOC and 3763 were LOC. Early-onset patients were more likely to be non-white, and intrahepatic cholangiocarcinoma. At diagnosis, patients had advanced AJCC stage, lymph node metastase and distant metastase. The EOC patients were more likely to receive surgery, radiotherapy, and chemotherapy than later-onset patients. Multifactorial COX analysis indicated that EOC patients had lower mortality risk than later-onset patients, and similar results were obtained after PSM; Kaplan-Meier survival curves corroborated that early-onset patients exhibited better OS than later-onset patients, and this survival advantage persisted after PSM. Further subgroup analysis following matching demonstrated that early-onset patients had better OS than later-onset patients in the surgical subgroup, while there were no statistically significant differences in the radiotherapy and chemotherapy subgroups. Conclusion The EOC patients typically exhibit an intrahepatic presentation and generally experience a more favorable prognosis. Surgery emerged as a critical treatment modality significantly influencing the overall prognosis of EOC.

Etiological factors and pathophysiological mechanisms of the reparative process in various types of cephalohematoms and methods of their treatment

BACKGROUND: The evolutionarily formed biomechanism of childbirth in humans causes a high incidence of head injuries during the reproductive process. One of the indicators of cranial injury is cephalohematoma. Despite the presence of a number of protective and adaptive mechanisms on the part of the fetus, the frequency of subperiosteal hemorrhages remains high and does not tend to decrease. Modern knowledge about the etiology of cephalohematomas does not always fit into the framework of classical ideas about the causes of hemorrhage under the periosteum. The lack of a unified understanding of the pathomechanisms occurring in a long-term subperiosteal hemorrhage leads to a mismatch of tactical actions during their treatment and the development of complications.&#x0D; AIM: To assess the role of etiological factors in the formation of subperiosteal hemorrhage in newborns and to determine the main direction of the pathophysiological process during repair with various types of cephalohematomas and methods of treatment.&#x0D; MATERIALS AND METHODS: A study of 243 newborns with the presence of cephalohematomas of various localization for the period from 20182022 was carried out, an analysis of the etiological prerequisites, features of the reparative process with various volumes of hemorrhages and methods of treatment using descriptive statistics methods was carried out.&#x0D; RESULTS: The predominance of children with the presence of cephalohematomas with a history of the absence of hydraulic protection of the head due to early rupture of amniotic fluid was revealed in relation to other mechanical factors of intranatal damage. The greatest number of subperiosteal hemorrhages was noted in newborns from multiparous mothers. The main non-traumatic factor contributing to the formation of cephalohematomas was the factor of infectious effect on the fetus. The predominance of osteomalacic processes with medium and large volumes of cephalohematomas in relation to small-sized cephalohematomas, which had a tendency to early ossification, was noted. The effectiveness of therapeutic aspiration was noted in all cases of observation of newborns from the surgical subgroup.&#x0D; CONCLUSIONS: One of the most significant etiological factors for the occurrence of cephalohematomas in the observation group was the factor of intranatal mechanical trauma to the soft tissues of the head, due to the lack of hydraulic protection. The numerical predominance of newborns with subperiosteal hemorrhages from multiparous mothers contradicts the basic physiological canons of the biomechanism of labor and may be due to the high incidence of the infectious factor. The direction of the pathophysiological process in the course of repair in case of periosteal detachment may depend not only on microenvironmental factors, but also be determined by the amount of hemorrhage. The use of puncture treatment for cephalohematomas can significantly reduce the number of complications associated with long-term persistence of subperiosteal hemorrhage.

Assessment of prognostic value of preoperative neutrophil-to-lymphocyte ratio for postoperative mortality and morbidity.

The preoperative elevated neutrophil-to-lymphocyte ratio (NLR) was reported to be associated with poorer outcomes after cancer and cardiovascular surgeries. It is unclear, however, if the predictive value is particular or if it may be applied to other types of surgery. We aimed to assess the prognostic value of preoperative NLR levels for morbidity and mortality after various surgery and determine an optimal threshold for NLR. We conducted a cohort analysis on patients receiving surgery at Sichuan University West China Hospital between 2018 and 2020. Multivariable piecewise regression analysis were used to determine the optimal cutoff value of NLR. Subgroup analysis were performed to verify the correlation. Sensitivity analysis was used to explore the effect of different thresholds. We obtained data from 136,347 patients. The optimal cutoff of NLR was determined as 3.6 [95% CI (3.0, 4.1)] by piecewise regression method. After multivariable adjustment, preoperative high NLR remained significantly associated with increased in-hospital mortality (aOR, 2.19; 95% CI, 1.90-2.52; p < 0.001) and ICU admission after surgery (aOR, 1.69; 95% CI, 1.59-1.79; p < 0.001). Subgroup analyses confirmed the predictive value of high NLR in multiple surgical subgroups, including general, orthopedic, neurosurgical, and thoracic surgery subgroups, otorhinolaryngology, head and neck surgery, and burn plastic surgery. A NLR threshold of 3.6 gave excellent predictive value, whether employed alone or added in an extended model. In conclusion, the association of elevated NLR with higher mortality and ICU admission can be extended to a wider range of procedures. NLR threshold of 3.6 could provide good prognostic value for the prognostic model.

Kids Voices, the perioperative experience of emergency surgery from children’s perspectives: A qualitative study

ObjectiveThe study aimed to better understand children’s emergency perioperative experience, a little researched topic. Current literature shows discrepancies between child and adult perceptions for the same healthcare experience. Acquisition of knowledge from the child’s perspective can be utilized to improve perioperative care. MethodThis qualitative study included children (4–15 years) undergoing emergency surgery requiring general anesthesia for manipulation under anesthesia (MUA) and appendicectomy. Recruitment was opportunistic with the aim to recruit a minimum of 50 per surgical subgroup, with 109 children interviewed via telephone postoperatively. Data analysis was performed using qualitative content analysis. Participants varied in terms of age, gender, diagnosis and previous perioperative experience. ResultsQualitative content analysis found three overarching themes in association with the perioperative process: (1) fearful/apprehensive, (2) perception of powerlessness and (3) perception of trust and security. Two overarching themes were found from data relevant to the perioperative environment: (1) poor adaptation of the care environment to the children’s needs and (2) positive adaptation of the care environment to the children’s needs. Conclusion and Practice implicationsThe themes identified provide valuable insight into children’s perioperative experience. Findings are of value to stakeholders in healthcare and are expected to inform strategies to optimize the quality of healthcare.

Method considerations and study protocol for a Nordic multi-centre prospective study on outcomes in rare paediatric epilepsy surgery subgroups.

Epilepsy surgery is a therapeutic option for selected children with drug-resistant epilepsy. Children who are surgical candidates have a high prevalence of neurodevelopmental comorbidities. There is a lack of adequately sized prospective studies in a number of rare surgical subgroups, especially of outcome domains such as cognitive level and health-related quality-of-life. In this article, we describe method considerations and a study protocol for a Nordic population-based multi-centre follow-up programme covering seizure as well as non-seizure outcomes in children aged <4 years undergoing resective epilepsy surgery and children aged ≤18 years undergoing hemispherotomy, callosotomy or surgery for hypothalamic hamartoma.

Opioids and pediatric urology: A prospective study evaluating prescribing habits and patient postoperative pain and narcotic utilization

Few pediatric urologists believe patients require a majority of the doses of opioids prescribed to them postoperatively. Seeking a better understanding of postoperative pain and analgesia in pediatric urology patients may help reduce opioid over prescription while still adequately managing postoperative pain. We sought to better understand: 1) the postoperative pain levels experienced by pediatric urology patients, 2) the factors that correlate with postoperative pain and number of opioids consumed following pediatric urologic procedures, and 3) the patients who do not require opioids after surgery. Pediatric patients undergoing circumcision, inguinal hernia repair, orchidopexy, or hypospadias repair were eligible to participate. Patients were enrolled in the prospective cohort on the day of the procedure. For each of the first 7 postoperative days, patients' parents completed a text message-based questionnaire, quantifying their child's pain level and the doses of pain medication the child consumed. 165 participants were enrolled. 57 patients underwent circumcision, 54 underwent orchiopexy, 32 underwent hypospadias repair, and 22 underwent inguinal hernia repair. For all procedure types, pain scores (p<0.01) and doses of oxycodone consumed were highest on postoperative day one and steadily declined thereafter. Overall, average 7-day pain score (2.02; 0.86-5.14) and doses of narcotics consumed (3.50; 0-5) were low. Patients in each surgical subgroup were prescribed narcotics in excess of what was consumed. There was an average excess of 10.9 doses (0-39.0) for hypospadias repair, 8.6 (1.0-30.0) for circumcision, 9.0 (3.0-21.0) for inguinal hernia repair, and 6.1 (0-22.0) for orchiopexy. Overall, reported pain scores and number of narcotics consumed were low regardless of surgery type. Opioids were overprescribed regardless of surgery type. Our findings indicate that level of pain and opioid use varies by procedure type, but that number of narcotics prescribed greatly exceeds number needed.

Opioid use after elective spine surgery: Do spine surgery patients consume less than prescribed today?

BackgroundThe opioid epidemic in the US has led prescribers to reevaluate postoperative pain control particularly in the field of spine surgery, where postoperative analgesia requirements and consumption have historically been high. There is a need to mitigate the quantity of unused pills after surgery by adjusting prescribing practices. Achieving the balance of pain control after surgery without overprescribing opioids may be accomplished by developing a modified approach to prescribing practices; however, there is a need to first understand the opioid requirements of the modern spine surgery patient with respect to their elective spine surgery. Therefore, the primary aim of this study was to determine the percentage of opioids not utilized at 90-days after elective spine surgery. Secondary aims were to identify differences in the percentage of unused opioids between surgical subgroups and preoperative opioid status, to determine factors associated with opioid utilization, and to estimate the distribution of opioids consumed to control pain up to the 90th percentile in each surgical subgroup. MethodsIn this prospective, observational cohort study, adults undergoing elective spine surgery at a multi-surgeon, single center were prospectively enrolled and divided into subgroups: anterior cervical, lumbar decompression, and short-segment lumbar fusion. Prescribed MMEs were identified from prescriptions, consumed MMEs were obtained from pill counts, and the percent leftover was calculated. Distributions of MMEs consumed were analyzed to compare utilization between preoperative opioid users or non-users within each surgical subgroup. ResultsOf 117 patients, 41.9% were preoperative opioid users. The percentage of unused opioids by surgical subgroup was: 45.4% cervical, 57.3% lumbar decompression, and 37.4% lumbar fusion (p=0.066). The percentage of unused opioids by preoperative opioid exposure was greater in the opioid non-users (58.0%) than users (28.4%, p<0.001)). Regression analysis showed that surgical subgroup and preoperative opioid exposure were associated with leftover opioids. ConclusionsAt 90-days, the percentage of unused opioids was over 45% in this cohort of elective spine surgery patients and was nearly double in the group without preoperative opioid exposure. These results suggest the modern elective spine surgery patient is using less opioids than prescribed, supporting the conclusion that the number of MMEs prescribed can be reduced to minimize quantities of leftover pills available for diversion, without sacrificing the priority of appropriate postoperative pain control.

Does Examined Lymph Node Count Influence Survival in Surgically Resected Early‑stage Pulmonary Typical Carcinoid Tumors?

We aimed to evaluate the prognostic impact of the number of examined lymph nodes (ELNs) in resected early‑stage pulmonary typical carcinoid tumors (TC). Patients who underwent sublobar resection and lobectomy for stage T1N0M0 TC between 2004 and 2016 were identified from the Surveillance, Epidemiology, and End Results database and enrolled in the ELNs≥4 or ELNs<4 groups (optimal cutoff using X-tile). Propensity score matching balanced baseline intergroup characteristics. Kaplan-Meier curve and log-rank test were used to calculate and compare overall survival (OS) rates. Cox proportional hazard model analysis was used to identify independent prognostic factors. Among 2234 participants, 961 (43.02%) and 1273 (56.98%) had ELNs <4 and ≥4, respectively. The 5-year OS was significantly higher in the ELNs≥4, compared with ELNs<4, group, both before and after propensity score matching (95.41% vs. 89.71%, P<0.001 and 95.24% vs. 90.28%, P=0.004), respectively. Surgical subgroup analysis confirmed this survival trend in the lobectomy and sublobar resection groups. Tumor size-based subgroup analysis revealed superior OS with ELNs≥4 than ELNs<4 for tumors measuring 1.1-3.0cm but not for tumors <1.0cm. Multivariate Cox analysis showed that ELN≥4 contributed to improved OS. The higher the ELNs, the greater the long-term survival rate in patients with early‑stage TC. Therefore, we recommend at least 4 ELNs as the cutoff value for evaluating the prognosis of early‑stage TCs, especially for patients with a tumor size of 1.1 to 3.0cm.

Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study

ObjectiveCardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States. MethodsWe surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes. ResultsThere were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04–0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions. ConclusionAmong IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

The effect of different frames filters on the prevention of pulmonary embolism in fracture patients subsequent with deep venous thrombosis on a multicenter prospective observational study

BackgroundA retrievable inferior vena cava filter (RIVCF) is used for the prevention of a pulmonary embolism, especially originated from deep venous thrombosis (DVT). However, which frame of RIVCF has an better effect on the specific thrombus has not been reported. MethodsAll patients enrolled underwent RIVCF placement in the study, and the placement and retrieval followed the respective instructions of different brands of RIVCFs. During the study period, the frame of the filter, the combined fracture site and operation, and the filter trapped embolus (TE) were collected. The primary observation indicators of this study were the occurrence of TE in two frames of filters and different fracture sites. Secondary observation indicators were the occurrence of TE with two different frames filters in different fracture site and surgical site subgroups. ResultsIn all 2892 patients enrolled, RIVCF TE was detected in 308 cases (10.7%) according to our definition. Among them, there were 1968 cases of fusiform RIVCF and 924 cases of umbrella RIVCF. There were 663 patients combined with fractures before DVT. The incidence of TE was significantly higher in patients with fusiform RIVCF (230 [74.68%]) than in those with umbrella RIVCF (78 [25.32%]) (P < .05). In patients with below-the-knee fracture surgery, there was significant difference in the incidence of TE between the two frames of RIVCF (P < .05). ConclusionsThis conclusion suggests that, in patients with DVT secondary to below-the-knee fracture, the detached thrombus may be more suitable for prophylaxis with fusiform frame RIVCF.