Unplanned Surgery Research Articles

Development and validation of a machine learning-based nomogram for prediction of unplanned reoperation post-spinal surgery within 30 days

Unplanned reoperation post-spinal surgery (URPS) leads to prolonged hospital stays, higher costs, decreased patient satisfaction, and adversely affects postoperative rehabilitation. This study aimed to develop and validate prediction models (nomograms) for early URPS risk factors using machine learning (ML) methods, aiding spine surgeons in designing prevention strategies, promoting early recovery, reducing complications and improving patient satisfaction. Medical records of 639 patients who underwent reoperation post-spinal surgery (RPS) from the First Affiliated Hospital of Air Force Medical University (2018 - 2022) were collected, including baseline indicators, perioperative indicators, and laboratory indicators. After applying inclusion and exclusion criteria, 122 URPS and 155 non-URPS patients were identified and randomly divided into training (82 URPS, 111 non-URPS) and validation (40 URPS, 44 non-URPS) cohorts. Three ML methods (LASSO regression, Random Forest, and SVM-RFE) were used to select feature variables, and their intersection was used to develop the prediction model, tested on the validation cohort. Six factors-implant, postoperative suction drainage (PSD), gelatin sponge (GS), anticoagulants (ATG), antibiotics (ATB), and disease type (DT)-were identified to construct a nomogram diagnostic model. The area under the curve (AUC) of this nomogram was 0.829 (95% CI 0.771-0.886) in the training cohort and 0.854 (95% CI 0.775-0.933) in the validation cohort. Calibration curves demonstrated satisfactory agreement between predictions and actual probabilities. The decision curve indicated clinical usefulness with a threshold between 1% and 90%. The established model can effectively predict URPS in patients and can assist spine surgeons in devising personalized and rational clinical prevention strategies.

Embolic Materials' Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score–Matched Analysis of 1070 Cases

BACKGROUND AND OBJECTIVES: Multiple preferences exist for embolic materials selection in middle meningeal artery embolization (MMAE) for chronic subdural hematoma with limited comparative literature data. Herein, we compare different embolic materials. METHODS: Consecutive patients undergoing MMAE for chronic subdural hematoma at 14 North-American centers (2018-2023) were classified into 3 groups: (a) particles, (b) Onyx, (c) n-butyl cyanoacrylate (n-BCA). The end points were unplanned rescue surgery, radiographic success (≥50% reduction in hematoma thickness at last imaging “minimum of 2 weeks”), and major complications. Initial unmatched analysis compared the 3 groups; subsequent propensity score matching (PSM) compared particles vs liquid embolics (groups b and c combined). Additional subgroup PSM analyses compared particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA. All matched analyses controlled for age, sex, concurrent surgery, previous surgery, hematoma thickness, midline shift, pretreatment antithrombotics, and baseline modified Rankin Scale. RESULTS: Eight hundred and seventy-two patients (median age 73 years, 72.9% males) underwent 1070 MMAE procedures. Onyx was most used (41.4%), then particles (40.3%) and n-BCA (15.5%). Surgical rescue rates were comparable between particles, Onyx, and n-BCA (9.8% vs 7% vs 11.7%, respectively, P = .14). Similarly, radiographic success (78.8% vs 79.3% vs 77.4%; P = .91) and major complications (2.4% vs 2.3% vs 2.5%; P = .83) were comparable. The PSM comparing particles vs liquid generated 128 matched pairs; general anesthesia and bilateral procedures were significantly higher in particles (37.8% vs 21.3%; P = .004 and 39.8% vs 27.3%; P = .034, respectively). No differences in surgical rescue, radiographic improvement, or major complications were noted (P > .05). Concurrently, PSM comparing particles vs Onyx, particles vs n-BCA, and Onyx vs n-BCA, resulted in 112, 42, and 40 matched pairs, respectively, without differences in surgical rescue, radiographic success, or major complications (P > .05). CONCLUSION: We found no differences in radiological improvement, surgical rescue, or major complications between embolic materials in MMAE. Current randomized trials are exclusively using liquid embolics, and these data suggest that future trials involving particles are likely to produce similar outcomes.

Ilizarov versus ORIF for Open AO Type-C Pilon Fractures

Objective: This study aimed to evaluate the clinical effectiveness of ORIF versus Ilizarov for the management of Type C closed pilon fractures of the distal tibia at 12 months follow up. Methods: This retrospective cross sectional study was conducted at Jinnah Postgraduate Medical Center (JPMC) between 29th May 2015 and 27th November 2019 that included patients 18 years and older diagnosed with open AO type C pilon fractures. The primary outcome was the patient-reported Disability Rating Index (DRI) months. While the secondary outcomes were quality of life assessment using the patient satisfaction form (SF-12) and AOFAS-Ankle Hindfoot Score. Radiographs were assessed for fracture healing, time to healing, and malalignment. Results: Fifteen patients underwent ORIF, while 26 patients were treated with Ilizarov, there was no statistically significant difference in DRI scores at 12 months between the two groups. In terms of clinical outcomes, both groups had comparable results throughout the follow-up period. The number of unplanned surgical procedures was not statistically significant (p=0.73), 26.92% (n=7) in the Ilizarov as compared to 33.33% (n=5) in the ORIF group. Conclusion: Among patients with an acute, displaced, intra-articular fracture of the distal tibia, neither external fixation nor locking plate fixation resulted in superior disability status at 12 months. Patient factors may need to be considered in deciding the optimal approach. doi: https://doi.org/10.12669/pjms.40.10.8941 How to cite this: Shaikh SA, Tanveer MO, Tahir M, Ahmed N. Ilizarov versus ORIF for Open AO Type-C Pilon Fractures. Pak J Med Sci. 2024;40(10):2213-2218. doi: https://doi.org/10.12669/pjms.40.10.8941 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Exploring Caesarean Birth 8: Discharge Planning and Education After Caesarean Birth

In the final article in this series, Leonie Rastas discusses discharge planning and education by maternity units after caesarean birth. Australia’s caesarean birth rate has risen 500% from the 1980 rate of 7%. The caesarean section (C-section) rate is predicted to reach 45% by 2030.1 This has impacted discharge planning and education by maternity units, particularly considering shortened hospital stays. Given every pregnancy is at risk of surgical intervention, it is incumbent on antenatal educators to include the implications of caesarean birth and the recovery expectations to help minimise the aftershock of unplanned surgery.

Comparing Deprivation vs Vulnerability Index Performance Using Medicare Beneficiary Surgical Outcomes

Health care researchers, professionals, payers, and policymakers are increasingly relying on publicly available composite indices of area-level socioeconomic deprivation to address health equity. Implications of index selection, however, are not well understood. To compare the performance of 2 frequently used deprivation indices using policy-relevant outcomes among Medicare beneficiaries undergoing 3 common surgical procedures. This cross-sectional study examined outcomes among Medicare beneficiaries (65 to 99 years old) undergoing 1 of 3 common surgical procedures (hip replacement, knee replacement, or coronary artery bypass grafting) between 2016 and 2019. Index discriminative performance was compared for beneficiaries residing in tracts with high- and low-deprivation levels (deciles) according to each index. Analyses were conducted between December 2022 and August 2023. Tract-level deprivation was operationalized using 2020 releases of the area deprivation index (ADI) and the social vulnerability index (SVI). Binary outcomes were unplanned surgery, 30-day readmissions, and 30-day mortality. Multivariable logistic regression models, stratified by each index, accounted for beneficiary and hospital characteristics. A total of 2 433 603 Medicare beneficiaries (mean [SD] age, 73.8 [6.1] years; 1 412 968 female beneficiaries [58.1%]; 24 165 Asian [1.0%], 158 582 Black [6.5%], and 2 182 052 White [89.7%]) were included in analyses. According to both indices, beneficiaries residing in high-deprivation tracts had significantly greater adjusted odds of all outcomes for all procedures when compared with beneficiaries living in low-deprivation tracts. However, compared to ADI, SVI resulted in higher adjusted odds ratios (adjusted odds ratios, 1.17-1.31 for SVI vs 1.09-1.23 for ADI), significantly larger outcome rate differences (outcome rate difference, 0.07%-5.17% for SVI vs outcome rate difference, 0.05%-2.44% for ADI; 95% CIs excluded 0), and greater effect sizes (Cohen d, 0.076-0.546 for SVI vs 0.044-0.304 for ADI) for beneficiaries residing in high- vs low-deprivation tracts. In this cross-sectional study of Medicare beneficiaries, SVI had significantly better discriminative performance-stratifying surgical outcomes over a wider range-than ADI for identifying and distinguishing between high- and low-deprivation tracts, as indexed by outcomes for common surgical procedures. Index selection requires careful consideration of index differences, index performance, and contextual factors surrounding use, especially when informing resource allocation and health care payment adjustment models to address health equity.

Clinical effects of hybrid debranching technique for acute Stanford type A aortic dissection

BackgroundTo investigate the clinical effects and safety of the hybrid debranching technique for patients with acute Stanford type A aortic dissection (AD).MethodsOne hundred nine patients with acute Stanford type a AD were selected and divided into observation group and control group according to the different surgical methods. Fifty-five patients in the observation group were treated with hybrid debranching, and 54 patients in the control group were treated with Sun’s operation. The operation duration, clamp time, cardiopulmonary bypass duration, volume of blood transfusion, ventilator application duration, duration of stay in the intensive care unit, aortic rupture, second thoracotomy due to hemorrhage, gastrointestinal hemorrhage, stroke, paraplegia, renal failure, and all-cause mortality were recorded. Postoperative follow-up was conducted. The number of cases that underwent follow-up and the number of cases with complete thrombosis of the false aneurysm cavity detected by computed tomography angiography (CTA) was recorded.ResultsThe surgical success rate was 100% in both groups, and there were no cases with unplanned secondary surgery. Compared with the control group, only the difference in the volume of blood transfusion was not significantly significant between the two groups (P = 0.052), while the rest of the observation indicators were significantly lower in the observation group than in the control group (P < 0.001 for all). The proportion of cases with complete thrombosis of the false aneurysm cavity was significantly higher in the observation group than in the control group at 3 and 6 months after surgery (P < 0.05).ConclusionIn patients with acute Stanford type A AD involving the arch, the hybrid debranching technique was safe and effective. It was recommended for patients with advanced age and a high risk of intolerance to deep hypothermic circulatory arrest.

Preoperative CT Scans Prior to Distal Tibial Intramedullary Nailing Do not Change Treatment Decisions or Surgical Outcomes.

Distal tibia shaft fractures have a high association with posterior malleolar fractures (PMFs); hence, a preoperative ankle CT scan is commonly obtained. The purpose of this study was to determine whether a CT scan for distal third tibia shaft fractures is associated with differences in recognition of a posterior malleolus fracture (PMF), treatment of an identified PMF, outcomes, and postoperative complications. We retrospectively reviewed cases of adult patients with distal third tibia shaft fractures treated with an intramedullary nail between 2018 and 2020. Patients were divided into 2 groups based on whether they received a preoperative ankle CT scan. Outcomes included surgical time, the rate of missed PMFs or postoperative PMF displacement, the treatment of the PMFs, postoperative weight-bearing restrictions, Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS Global-10) scores, and unplanned revision surgeries. 124 patients (age 45 ± 18 years; 39.5% female) with distal third tibia shaft fractures treated with intramedullary nailing and with minimum 6 months of follow-up were reviewed. 26 patients received preoperative CT scans, and 98 patients did not have CT scans. The rate of detected PMF was 69.2% (N = 18) in patients with CT and 55.1% (N = 54) in patients without CT (P = 0.19). No significant differences were observed in all outcomes between the 2 groups (P > 0.05). 3 PMFs not visible on radiographs were identified on CT, and they did not require fixation and did not displace. PMFs that were greater than one-third of the joint surface were more likely to have a preoperative CT (P < 0.01). Preoperative CT scans for distal third tibia shaft fractures may be useful in characterizing large PMFs; however, this knowledge does not translate into shorter surgical time, increased fixation rates, decreased unplanned revision surgery, or improved patient-reported outcomes. Discovery of PMFs did not always lead to fixation, and PMFs without fixation did not become further displaced.

Induced membrane technique for malignant bone tumours of the humerus.

The aim of this study was to report on mid- to long-term results following large humeral tumoral resection and reconstruction with the induced-membrane technique in skeletally immature patients suffering from primary malignant bone tumours. A retrospective analysis identified all children who underwent the two stages of a humeral reconstruction using the induced-membrane technique for primary malignant humerus tumours between 2002 and 2020. Functional assessment was conducted by an independent observer using the Musculoskeletal Tumor Society (MSTS) scoring system for the upper limb. Radiological assessment was performed by two independent observers and the healing index was calculated (i.e., months/cm). Eight adolescents (5 osteosarcomas and 3 Ewing sarcoma), with a mean age of 14.2 years (SD = 2.7), were included. The mean length of the bone resection was 17.4cm (SD = 3.8), and the mean delay of the resection and reconstruction stages was 9.4 months (SD = 4). The mean follow-up was 6.6 years (SD = 4.3). The mean MSTS score was 77.4% and the global average healing index was 1.04 months/cm (SD = 2.2). Four complications (i.e., prominence device, fracture, aseptic pseudarthrosis, radial palsy) and one local recurrence were observed in four patients, requiring four unplanned surgical procedures in three patients. One patient died fourteen years after the initial treatment due to a lung recurrence. The induced-membrane technique is an effective and safe alternative for reconstructing large humeral bone defects after tumour resection in adolescents. Although this is a two-stage technique, it gives good functional results comparable to other strategies found in the literature. IV.

ThP1.13 - Short term safety outcomes of immediate pre-pectoral implant based reconstruction

Abstract Aims In the UK up to 43% of women undergo immediate breast reconstruction (IBR) following mastectomy for breast cancer. Implant reconstruction is the commonest form of breast reconstruction and pre-pectoral techniques have been introduced with the aim of improving cosmetic outcome and avoiding animation. To assess the safety of pre-pectoral implant based breast reconstruction (PPBR), including infection rates, 30 day re-admission to hospital, need for unplanned surgery and implant loss at 3 months. Methods A retrospective study of 80 consecutive women who underwent PPBR for breast cancer or risk reduction between October 2020 and October 2023. Demographic, operative and complication data were collected. Results Eighty women (70 cancer, 8 risk reducing and 2 cancer/risk reducing) underwent 94 PPBR procedures (80 Skin sparing mastectomies and 14 Nipple and skin sparing mastectomies) with a mean age of 51.5 (range 28 to 79) years and a BMI of 25.2 kg/m2. 7 (8.8%) of women were smokers. The mean implant size used was 385cc (range 160cc to 650cc) with a mean breast weight of 448.6g (range 45g to 1700g). 10 (12.5%) women required oral antibiotics for wound infection with a further 2 (2.5%) women requiring re-admission within 30 days for IV antibiotics. 17 (21.3%) developed a seroma with 8 (47.1%) requiring drainage. No implant losses were recorded within 3 months of reconstruction. Conclusion We have demonstrated that PPBR is a good option for patients of a wide age range with a large variation in breast size with minimal complications and no implant losses.

Impact of causative organism identification on clinical outcomes after minimally invasive posterior fixation for thoracolumbar pyogenic spondylitis: multicenter retrospective cohort study.

This study aimed to evaluate the difference in treatment duration and unplanned additional surgeries between patients with unidentified causative organisms on empiric antibiotics and those with identified organisms on selective antibiotics in treating thoracolumbar pyogenic spondylitis with minimally invasive posterior fixation. This multicenter retrospective cohort study included patients with thoracolumbar pyogenic spondylitis refractory to conservative treatment who underwent minimally invasive posterior fixation. Patients were divided into the identified (known causative organism) and unidentified groups (unknown causative organism). We analyzed data on demographics, antibiotic use, surgical outcomes, and infection control indicators. We included 74 patients, with 52 (70%) and 22 (30%) in the identified and unidentified groups, respectively. On admission, the identified group had higher C-reactive protein (CRP) levels and more iliopsoas abscesses. The duration to postoperative CRP negative was similar in the identified and unidentified groups (7.13 vs. 6.48 weeks, p = 0.74). Only the identified group had unplanned additional surgeries due to poor infection control, affecting 6 of 52 patients (12%). Advanced age and causative organism identification increased the additional surgery odds (odds ratio [OR], 8.25; p = 0.033 and OR, 6.83; p = 0.034, respectively). The use of empiric antibiotics in minimally invasive posterior fixation was effective without identifying the causative organism and did not prolong treatment duration. In patients with identified organisms, 12% required unplanned additional surgery, indicating a more challenging infection control. Causative organism identification was associated with the need for additional surgery, suggesting a more cautious treatment strategy for these patients.

Late diagnosis of Marfan syndrome is associated with unplanned aortic surgery and cardiovascular death

BackgroundMarfan syndrome (MFS) guidelines recommend optimal pharmacologic therapy (OPT) and replacement of the ascending aorta (RAA) at 5.0 cm in diameter to prevent acute type A aortic dissection (ATAAD) and death. The effect of early MFS diagnosis and initiation of therapy on outcomes is not known. Therefore, we sought to evaluate the effect of age at MFS diagnosis and therapy initiation on delayed RAA and death. MethodsThis retrospective observational cohort study with long-term follow-up included consecutive patients with MFS, pathogenic FBN1 variant, and regular visits to a European Reference Network Center. We considered MFS diagnosis at age ≥21 years late and OPT initiation at age <21 years early. Outcomes were delayed RAA with aneurysm diameter >5.0 cm or ATAAD and death from all causes. We used landmark design starting at age 21 years to determine associations with outcomes. ResultsThe study group consisted of 288 patients (45.1% male), including 169 patients with late diagnosis of MFS (58.7%) and 63 with early OPT (21.9%). During mean follow-up of 25 ± 14.7 years, 78 patients had delayed RAA, with 42 operations for ATAAD and 36 for aneurysms ≥5.0 cm. There were 33 deaths, including 11 deaths late after ATAAD. All deaths were cardiovascular. Late diagnosis, but not early OPT, showed univariate association with delayed RAA (P < .001) and death (P = .025). Multivariate Cox regression analysis confirmed late diagnosis as predictor of delayed RAA (hazard ratio, 8.01; 95% confidence interval, 2.52-25.45; P < .001) and death (hazard ratio, 4.68; 95% confidence interval, 1.17-18.80; P = .029). ConclusionsLate diagnosis of MFS is associated with delayed surgery and death.

Community Privilege and Unplanned Surgery for Access-Sensitive Surgical Conditions.

We sought to define the association of privilege on rates of unplanned surgery and perioperative outcomes for access-sensitive surgical conditions. Social determinants of health (SDOH) are critical in influencing timely access to healthcare. Privilege represents a right, benefit, advantage, or opportunity that positively influences all SDOH. The California Department of Health Care Access and Information (HCAI) database identified patients who underwent abdominal aortic aneurysm repair, ventral hernia repair, or colectomy for colon cancer between 2017 and 2020 and was merged using ZIP codes with the Index of Concentration of Extremes, a validated measure of racial and economic privilege obtained from the American Community Survey. Clustered multivariable regression was performed to assess the association between privilege and outcomes. Among 185,316 patients who underwent a surgical procedure for one of three access-sensitive surgical conditions, roughly 1 in 5 individuals resided in areas with the highest (Q5; n=37,308; 20.1%) or lowest (Q1; n=36,352, 19.6%) privilege. Nearly one-half of the surgeries were unplanned (n=88,814, 46.9%), and colectomy for colon cancer was the most performed emergent procedure. Patients residing in the lowest privileged areas had higher rates of unplanned surgery compared with those residing in the highest privilege (Q1; 55.4% vs. 39.4%; referent: Q5; adjusted odds ratio [OR], 1.23, 95%CI 1.16-1.31; P<0.001). For each access-sensitive surgical condition, patients in the least privileged areas were more likely to experience higher rates of inpatient mortality (Q1; 3.1% vs. 2.1%; referent: Q5; adjusted OR, 1.41, 95%CI 1.24-1.60; P<0.001), perioperative complications (Q1; 30.4% vs. Q5; 23.8%; referent: Q5; adjusted OR, 1.24, 95%CI 1.18-1.31; P<0.001) and extended hospital stays (Q1; 26.3% vs. 20.1%; referent: Q5; adjusted OR, 1.16, 95%CI 1.09-1.22; P<0.001). Privilege was associated with rates of unplanned surgery and adverse clinical outcomes. This indicates the role privilege as a key SDOH that influences patient access to and quality of surgical care.

Social Capital and Surgery Access Among Medicare Beneficiaries.

To compare the rates of unplanned procedures for access-sensitive surgical conditions among beneficiaries living in census tracts of varying social capital levels. Access-sensitive surgical conditions are conditions ideally screened for and treated in an elective setting. However, when left untreated, these conditions may result in unplanned (i.e., urgent or emergent) surgery. It is possible that social capital-the resources available to individuals through their membership in a social network-may impact the likelihood of a planned procedure occurring. Medicare beneficiaries who underwent one of three access-sensitive procedures (abdominal aortic aneurysm repair, colectomy for cancer, and ventral hernia repair) between 2016-2020 were stratified by their census tract level of social capital, the exposure variable. Outcomes included rate of unplanned surgery, readmission, 30-day mortality, and complications which were risk-adjusted with a logistic regression model that accounted for patient age, sex, race, comorbidities, and area deprivation. A total of 975,048 beneficiaries were included (mean [SD] patient age, 76 [7.6] years; 443,190 were male [45.45%]). Compared to patients from census tracts in the highest overall social capital decile, those from census tracts with the least social capital were on average more likely to undergo unplanned surgery (40.67% versus 35.28%, OR=1.26 P<0.001). Additionally, beneficiaries in these communities were also more likely to experience postoperative complications (24.99% versus 22.90%, OR=1.12 P<0.001), but there was no significant difference in rates of readmission or mortality. When evaluating only elective procedures, the differences between the lowest and highest social capital decile groups reduced significantly for complications (12.77% versus 12.11%, OR=1.06 P=0.04), the differences in mortality rates collapsed, and differences in readmission rates remained insignificant. These data suggest that Medicare beneficiaries who live in communities with lower social capital are more likely to undergo unplanned surgery for access-sensitive conditions. Efforts to improve social capital in these communities may be one strategy for reducing the rate of unplanned operations.

Whether unplanned excision on synovial sarcoma will influence the prognosis? An retrospective analysis of prognostic factors in 54 synovial sarcoma cases at a single center.

In this study, we examined the reason and prognosis of unplanned excision on synovial sarcoma. We retrospectively analyzed 54 patients diagnosed with synovial sarcoma between March 2013 and February 2021, including 26 cases of unplanned excision surgery. Patients were divided into two groups based on whether they underwent unplanned excision. Then, factors such as gender, age, tumor size, tumor location, American Joint Committee on Cancer (AJCC) staging, unplanned excision, time of onset, duration of disease, radiotherapy, chemotherapy, amputation, local recurrence factors, and death were statistically evaluated. The results of a multivariate analysis revealed that the AJCC staging is an independent factor for patient prognosis. When patients were divided into two groups, those who had undergone unplanned excision and those who had not, statistical analysis revealed that there was no difference of survival between two groups, but tumor size and AJCC staging had statistical difference. To further explore the influences of unplanned excision, we performed propensity score analysis with 1:1 matching using the nearest neighbor matching method to balance the covariates between the two groups. There was no difference of survival between two groups after propensity score matching. Unplanned excision is commonly performed in synovial sarcoma and do not impact the prognosis after extensive resection.

Feasibility and Success of Muscular Ventricular Septal Defect Occluders and Mushroom-Shaped Occluders in Transcatheter Patent Ductus Arteriosus Closure in Low-Weight Children: A Propensity Score-Matched Retrospective Analysis from a Chinese National Regional Health Center.

Muscular ventricular septal defect occluders (MVSDOs) have been attempted as an option in low-weight patients with patent ductus arteriosus (PDA). However, few studies have assessed the safety of transcatheter patent ductus arteriosus closure (TCPC) using MVSDO. Therefore, we compared the outcomes in low-weight patients who used MVSDO and mushroom-shaped occluder (MSO). Medical records of children under 10 kg (n = 417) who underwent TCPC from 2015 to 2021 at a Chinese health center were reviewed. They were divided into MSO (n = 372) and MVSDO (n = 45) groups. A 1:1 propensity score matching (PSM) was done considering gender, height, weight, body surface area (BSA), PDA diameter, and BSA-corrected PDA diameter. All 45 children in the MVSDO group (mean weight: 5.92 ± 1.32 kg) achieved successful immediate occlusion. One case in the MVSDO group experienced device migration within 24 h requiring unplanned surgery. MVSDO significantly ameliorated pulmonary artery hypertension. After PSM, each group comprised 41 children. The MVSDO group had a smaller effect on platelet counts (MVSDO vs. MSO = 259.85 ± 114.82 vs. 356.12 ± 134.37, p &lt; 0.001), a reduced incidence of thrombocytopenia (MVSDO vs. MSO = 2/41 vs. 7/41, p = 0.001), and a higher rate of residual shunting (MVSDO vs. MSO = 16/41 vs. 5/41, p = 0.005), compared with the MSO group. Thrombocytopenia resolved during hospitalization and micro-shunts disappeared by 6 months. No pulmonary artery or descending aortic secondary stenosis was observed in 1-year follow-up. MVSDO used in low-weight children is feasible, with high success and satisfactory postoperative and short-term follow-up outcomes, including lower thrombocytopenia incidence, compared to MSO. Further long-term studies with larger samples are recommended.

Cefadroxil is an option for Gram-positive bone and joint infections in adults

Background: Oral antimicrobial therapy for osteoarticular infections in adults is increasingly adopted; however, the preponderance of published data and experience with oral antibiotics involves agents such as fluoroquinolones, trimethoprim-sulfamethoxazole, and clindamycin. Data supporting the use of narrower-spectrum, stewardship-friendly oral antibiotics with favorable toxicities profiles (e.g. cefadroxil) are needed. Methods: We report a case series of adults who underwent surgery for monomicrobial Gram-positive osteomyelitis, native joint septic arthritis (NJSA), prosthetic joint infection (PJI), or other orthopedic hardware infection at our institution from January 2019 through January 2022 and who subsequently received at least two weeks of oral cefadroxil. We excluded patients who had polymicrobial infection or curative amputation, or who received cefadroxil only as suppressive antibiotic therapy (SAT). Our primary outcome of interest was treatment success during followup, defined as freedom from death, unplanned surgery for infection, or readmission for worsening infection. Results: We identified 22 patients who received cefadroxil for primary treatment of osteoarticular infection. The mean age was 57.6 years, mean weight 98.6 kg, 68% were male, and none had peripheral vascular disease. Infections included PJI in 12, NJSA in 8, osteomyelitis in 7, and other hardware infections in 5; some patients had multiple infectious syndromes. Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common pathogen (73%), followed by streptococci (18%), other methicillin-susceptible staphylococci (14%), and Cutibacterium acnes (5%). Half of patients received 120kg who had device infections with MSSA, two of which were managed with implant retention, suggesting pharmacokinetic/pharmacodynamic factors and biofilm burden could influence treatment outcome. Limitations of this study include its small sample size, noncomparative nature, lengthy initial intravenous antibiotic durations, and limited durations of followup. These data suggest cefadroxil merits investigation for adult osteoarticular infection in larger comparative (and ideally, prospective randomized) studies.

Urgency adjusted outcomes of emergency abdominal surgery for inflammatory bowel disease.

Patients undergoing emergency abdominal surgery for inflammatory bowel disease (IBD) are a complex cohort who are relatively poorly represented in published literature. This is partly due to the lack of consensus of the definition of the term emergency in IBD surgery. There is ongoing and recent work defining clinical urgency for unplanned surgical procedures and categorizing the high-risk surgical patient. This paper aims to report the difference in patient metrics and risks as recorded by the National Emergency Laparotomy Audit (NELA). Complete patient data, including histology, were available in the NELA database between 2013 and 2016. Urgency categories recorded by NELA are <2h, 2-6h, 6-18h, and >18h. Patient characteristics, physiology, biochemistry, and outcomes are reported according to these urgency categories with regression analysis used to compare differences between them. Mortality in Crohn's disease (CD) ranged from 1.4% in the >18h urgency to 14.6% in the most urgent. In ulcerative colitis (UC), this range was from 3.1% to 14.8%. In both CD and UC, there were significant trends in hemodynamic instability, serum white cell count, serum electrolytes and creatinine, and outcome measures length of stay and unplanned return to theater. Patients having emergency surgery for IBD are not a single cohort when considering physiology, blood biochemistry, or most importantly, outcomes. Risk counseling and management should reflect this. Hemodynamic changes are subtle and may be missed in this cohort.

Patient Characteristics and Postoperative Outcomes of Surgically Treated Inferior Pole Patellar Sleeve Fractures.

Despite representing over half of all pediatric patella fractures, inferior pole patellar sleeve fractures (PSFs) are a relatively uncommon pediatric injury. As a result, existing literature on PSFs is limited to case reports and small case series. The purpose of this study was to evaluate the radiographic and clinical characteristics of operatively treated PSFs as well as outcomes following surgical management. A retrospective review of all inferior pole PSFs requiring surgery from 2007 to 2023 was performed at a single urban tertiary care children's hospital. Cases were identified using diagnostic and billing codes. Patient demographics, injury characteristics, surgical techniques, and postoperative rehabilitation practices were recorded. Regional skeletal maturity, fracture characteristics, and postreduction patellar height were recorded. Postoperative complications were recorded and categorized using the modified Clavien-Dindo Classification System (CDS). Thirty-eight inferior pole PSFs were identified meeting study criteria. The majority of patients were male (86.8%), and the mean age at injury was 11.0 years (range: 7.2 to 15.0). Mean BMI was 21.1. Radiographically, the majority of patients were Epiphyseal Fusion Stage 0 (nonunion), with a median postreduction Caton-Deschamps index (CDI) of 1.2 (IQR: 1.1 to 1.3). These fractures were predominantly treated with suture-based fixation (84%). Postoperative immobilization varied within the cohort, and the initiation of knee ROM was permitted at a median of 3.5 (IQR: 2.0 to 4.6) weeks. All patients regained full range of motion and straight leg raise without extensor lag, and return-to-sport was achieved by a median of 17.6 weeks (IQR: 12.8 to 30.3). Complications occurred in 10 (26.3%) patients, with 3 (7.9%) requiring a return to the OR (CDS Grade III). Inferior pole PSFs appear to occur most commonly among prepubertal males of normal BMI and normal patellar height. Despite variable rehabilitation protocols, operative management resulted in restoration of extensor mechanism function. Eight percent of patients experienced complications requiring unplanned surgery. This large series improves our understanding of the epidemiology, injury characteristics, and postoperative outcomes of an operatively treated cohort of a rare injury pattern. Level IV.

The efficacy and safety of ureteroscopic lithotripsy and flexible ureteroscopy with continuous anticoagulant or antiplatelet drugs: A multicenter retrospective real-world study

Abstract Objective The objective of this study is to assess the effectiveness and safety of ureteroscopic lithotripsy and flexible ureteroscopy (fURS) for treating patients on anticoagulant (AC) or antiplatelet (AP) medications. Patients and Methods The study included 213 patients with urinary stones who underwent ureteroscopic lithotripsy or fURS between January 2019 and October 2022 at the Shanghai Municipal Hospital Urology Specialist Alliance. Among these patients, 15 received AC therapy, 193 received AP therapy, and 5 received both AC and AP therapy. Patients were divided into 3 groups based on the real-world management of antithrombotic drugs: the continuation group (n = 62), the discontinuation group (n = 91), and the discontinuation and bridge heparin group (n = 60). Intraoperative and postoperative outcomes were compared among the 3 groups. Results Age, sex, body mass index, stone location, stone size, stone side, and residual fragments were not different among the groups. None of the patients received blood transfusions or had thromboembolic events, emergencies for gross hematuria, significant bleeding-related complications, or unplanned secondary ureteroscopic surgery. The mean duration of hospital stay of the continuation group (3.97 days) was significantly lower than that of the discontinuation group (5.99 days) and the discontinuation and bridge heparin group (5.75 days) (p &lt; 0.001). Conclusions Ureteroscopic lithotripsy and fURS can be performed safely and effectively in patients on AC or AP drugs, resulting in reduced duration of hospital stay.

A Qualitative Study Exploring Women's Experiences of Unplanned Cesarean Surgery and Their Suggestions for Improving Care

The rate of unplanned cesarean birth is increasing and there is a growing body of evidence regarding the associated psychosocial harms. A phenomenological study exploring eight women's lived experiences of intrapartum cesarean birth in Nova Scotia was undertaken. Two groups of women were recruited, three receiving care from a midwife with transfer from a planned home birth and five women under the care of a physician. Semi-structured interviews were tape-recorded and transcribed. These data, combined with participantdiariesande-mails,wereanalyzedusingColazzi'smethod. Threemajorthemesemerged:1) Immediate and lingering emotional reactions, which were wide ranging, the majority negative, particularly fear, disappointment and self-doubt, 2) Mediating factors, most significantly, continuous contact with the baby and provider support, especially from midwives, and 3) Participant suggestions for improving care which included prenatal operating room (OR) tours, family-friendly OR policies, postnatal medical review with extended follow-up and peer support. This study adds to the already substantial evidence of associated psychosocial harms which can be mediated by concurrently reducing unnecessary cesarean surgery and implementing measures to improve the quality of cesarean care.