Postoperative laboratory testing in the era of outpatient total joint arthroplasty: Targeted patient selection and associated cost savings.

Background: With the advent of outpatient total joint arthroplasty (TJA), the days of routinely drawing postoperative labs (complete blood counts [CBCs] and metabolic panels [CMPs/BMPs]) to monitor for complications are behind us. However, there does exist a subset of at-risk patients that may benefit from diligent postoperative monitoring, though the circumstances under which labs should be ordered remains unclear and subject to surgeon discretion. A systematic review of the literature was therefore conducted to evaluate the utility of postoperative laboratory testing, approaches to targeted patient selection and associated cost-savings. Methods: The PubMed, MEDLINE, EBSCOhost, and Google Scholar electronic databases were searched on August 17, 2023, to identify all studies published since January 1, 2000, that evaluated the role of postoperative lab testing in TJA. (PROSPERO study protocol registration: CRD42023437334). Articles were included if a full-text English manuscript was available and the study assessed the utility of routine postoperative labs in TJA. 19 studies were included comprising 34,166 procedures. The mean Methodological index for Nonrandomized Studies score was 18.2 ± 1.5. Results: Abnormal postoperative lab results were common and infrequently required clinical intervention. Among several identified risk factors for patients that may benefit from postoperative laboratory monitoring, preoperative lab values proved excellent discriminators of transfusion requirement and metabolite-associated intervention. Selective testing demonstrated the ability to generate substantial cost-savings. Conclusion: Routine postoperative laboratory testing offers little clinical utility and produces unnecessary expenditures. Preoperative lab values offer the greatest predictive utility for postoperative transfusion requirement and metabolite-associated clinical intervention, with a preoperative hemoglobin threshold of 111.5 g/L offering an area under the curve (AUC) of 0.93 for predicting postoperative transfusion. Further investigations are needed for metabolic panel predictive models and should incorporate preoperative lab values. The refinement of such models can enable targeted patient selection to avoid unnecessary labs and generate substantial cost savings without compromising patient safety.

Greater readmission rates after total hip arthroplasty with discharge to a facility vs. home: A propensity score matched analysis.

Purpose: Provided that total hip arthroplasties (THA) are some of the most common surgical procedures performed, there is a necessity to understand all factors that contribute to risks of adverse outcomes postoperatively and to find solutions to avoid these events with preventive measures. This retrospective cohort study sought to assess differences in (1) postoperative complication rates, (2) readmission rates and reasons, and (3) demographic variables that contribute to readmissions based on discharge destination within the first 30 days after a THA. Methods: Patients undergoing THA (27130) between 2015 and 2020 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database based on procedural codes. Propensity score matching was then employed to reduce selection bias, and Chi-square tests and one-way analysis of variance (ANOVA) were performed. Multivariable analysis was then used to look for other factors associated with readmission risk. Results: 219,960 patients were identified with 189,841 discharged to home, 19,355 to a skilled nursing facility (SNF), and 10,764 to a rehabilitation facility. The rehabilitation and SNF cohorts both had greater rates of readmission (4.56 % home vs. 6.88 % SNF vs. 6.90 % rehabilitation, P<0.001) and any adverse event (AAE, 9.02 % vs. 18 % vs. 21.3 %, P<0.001) after matching. Older age, longer operative time, American Society of Anesthesiologists (ASA) classification four, chronic obstructive pulmonary disease (COPD), bleeding disorders, steroid use, and smoking were associated with an increased risk of readmission after THA. Conclusion: Overall, THAs were shown to have low postoperative complications and readmissions in all patient populations despite differences in discharge destination which continues to demonstrate the safety and validity of this often elective procedure. However, the statistically significant risk of complications and readmissions in addition to the higher costs associated should be accounted for when considering patient discharges to a non-home facility.

A case of gastrointestinal perforation following transarterial embolization for an intramural hematoma after cold snare polypectomy of an adenoma in the transverse colon.

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

Short-term outcomes with routine use of size ≥40 femoral heads in THA: A retrospective cohort study.

Background: Using larger femoral heads during total hip arthroplasty (THA) may result in a more stable hip. Greater volumetric wear and frictional torque, however, may result in increased postoperative complications. The purpose of this study was to compare outcomes of patients with femoral head size ≥40 mm compared to those with femoral head size <40 mm. Materials and methods: A retrospective chart review of 504 THAs performed by a single surgeon at a single institution from 2009 to 2016 was conducted. Following exclusions, 131 THAs were identified with femoral heads ≥40 mm and 348 THAs were identified with femoral heads <40 mm. In addition to demographic data, all postoperative complications were recorded. Plain radiographs were used to rule out/in periprosthetic osteolysis and/or acetabular loosening. Chi-square tests and Student's t-tests were used to compare categorical and continuous variables, respectively. Results: Mean follow-up period for the entire cohort was 5.5 years. Complications with ≥40 mm femoral heads included 1 superficial infection and 1 deep periprosthetic joint infection (PJI). There were no cases of dislocation, osteolysis, acetabular loosening, or trunnionosis. In contrast, complications with <40 mm femoral heads included 9 dislocations and 7 PJIs. Conclusion: The routine use of large femoral heads (≥40-mm) during THA appears to be a safe option for patients at short-term clinical follow-up. Notably, 0 patients had a clinical course complicated by dislocation, osteolysis, acetabular loosening, or trunnionosis. Level of evidence: Level III Retrospective Cohort Study.

Red light-induced localized release of carbon monoxide for alleviating postoperative cognitive dysfunction.

Inflammation within the central nervous system (CNS), which may be triggered by surgical trauma, has been implicated as a significant factor contributing to postoperative cognitive dysfunction (POCD). The relationship between mitigating inflammation at peripheral surgical sites and its potential to attenuate the CNS inflammatory response, thereby easing POCD symptoms, remains uncertain. Notably, carbon monoxide (CO), a gasotransmitter, exhibits pronounced anti-inflammatory effects. Herein, we have developed carbon monoxide-releasing micelles (CORMs), a nanoparticle that safely and locally liberates CO upon exposure to 650 nm light irradiation. In a POCD mouse model, treatment with CORMs activated by light (CORMs + hv) markedly reduced the concentrations of interleukin (IL)-6, IL-1ß, and tumor necrosis factor-alpha (TNF-α) in both the peripheral blood and the hippocampus, alongside a decrease in ionized calcium-binding adapter molecule 1 in the hippocampal CA1 region. Furthermore, CORMs + hv treatment diminished Evans blue extravasation, augmented the expression of tight junction proteins zonula occludens-1 and occludin, enhanced neurocognitive functions, and fostered fracture healing. Bioinformatics analysis and experimental validation has identified Htr1b and Trhr as potential key regulators in the neuroactive ligand-receptor interaction signaling pathway implicated in POCD. This work offers new perspectives on the mechanisms driving POCD and avenues for therapeutic intervention.

Laparoscopic colectomy for patients with poor American Society of Anesthesiology classifications.

INTRODUCTION: The American Society of Anesthesiologists (ASA) classification is used to assess the fitness of a patient for surgery. Whether laparoscopic surgery is appropriate for colorectal cancer patients with poor ASA performance status (PS) remains unclear. METHODS: Among 4585 patients who underwent colorectal surgery between 2016 and 2023, this study retrospectively reviewed all 458 patients with ASA-PS ≥3. Patients were divided into two groups: patients treated by open surgery (O group, n = 80); and patients treated by laparoscopic surgery (L group, n = 378). We investigated the impact of surgical approach on postoperative complications in patients with colorectal cancer and ASA-PS ≥3. RESULTS: Operation time was longer (170 min vs. 233 min, p < .001), blood loss was less (156 mL vs. 23 mL, p < .001), postoperative complications were less frequent (40.0% vs. 25.1%, p = .008), and hospital stay was shorter (23 days vs. 14 days, p < .001) in L group. Univariate analysis revealed rectal cancer, open surgery, longer operation time, and blood loss as factors significantly associated with postoperative complications. Multivariate analysis revealed open surgery (odds ratio [OR] 2.100, 95% confidence interval [CI] 1.164-3.788; p = .013) and longer operation time (OR 1.747, 95% CI 1.098-2.778; p = .018) as independent predictors of postoperative complications. CONCLUSION: Laparoscopic surgery provides favorable outcomes for colorectal cancer patients with poor ASA-PS.

From diagnosis to postoperative challenges: a comprehensive case report on 2q37 deletion syndrome with CHD.

Chromosomal 2q37 deletion syndrome, marked by developmental delays, distinctive facial features, and a spectrum of congenital anomalies, presents significant challenges in the cardiac management of affected individuals. This paper details the case of an 8-month-old male with 2q37 deletion syndrome, manifesting atrial and ventricular septal defects, patent ductus arteriosus, and right ventricular outflow tract stenosis, leading to a demanding postoperative course. Despite an initially stable post-surgery phase, the onset of junctional ectopic tachycardia necessitated prolonged veno-arterial extracorporeal membrane oxygenation support, highlighting the syndrome's potential for intricate postoperative courses. The complexities encountered in this case, including extended renal replacement therapy and delayed thoracic closure, underscore the syndrome's multisystem impact and the critical need for tailored, multidisciplinary care approaches. This report contributes to the growing body of knowledge on the cardiac implications of 2q37 deletion syndrome, emphasising the importance of individualised surgical strategies and the ongoing exploration of genotype-phenotype correlations in this rare genetic disorder.

Chinese American Pain Experience Project (CAPE): Perceptions, Expectations, and Attitudes on Pain Management among Chinese American Postoperative Patients.

INTRODUCTION: Chinese Americans are one of the fastest growing racial and ethnic groups and represent the largest subgroup of the Asian American population in the US and in New York City (NYC) where they number 573,528 in 2021. Despite their numbers, current pain perceptions, expectations, and attitudes of Chinese Americans remains poorly understood, especially as related to postoperative pain. OBJECTIVE: A better understanding of pain experience among Chinese American patients is needed to inform strategies on improving pain management satisfaction. METHODS: A total of 27 Chinese American postoperative patients from a NYC health system were recruited for face-to-face surveys and interviews with a trained bilingual and bicultural Community Health Worker. Questions from the Survey on Disparities in Quality of Healthcare and Kleinman's Explanatory Model of Illness were integrated into the survey and topic guide. Topics of discussion included satisfaction with healthcare and pain management during hospital stay and health beliefs and practices. RESULTS: More than half of participants experienced language challenges that made it difficult to communicate with healthcare staff. In general, high levels of satisfaction with pain management were reported; however, participants reported feeling less comfortable asking healthcare teams questions. Common themes across interviews included: (1) pain was an expected outcome of the procedure and was thus perceived as tolerable; (2) the wish to not be a burden to others; (3) concerns about side effects of pain medications; and (4) a cultural and language mismatch between healthcare teams and patients on words being used to elicit pain and discomfort. CONCLUSION: Our project findings can inform pain management strategies and tools to serve the Chinese American patient population.

Postoperative irradiation in stage II thymomas: is it worth it?-shedding some light in the guidelines' gray zone.

Thymomas are rare, indolent tumors. Early stages (I-II) benefit from surgical treatment, while locally advanced diseases (stages III-IV) usually require a multidisciplinary approach. The role of postoperative radiotherapy (PORT) on anterior mediastinum for radically resected Masaoka-Koga stage II thymomas remains controversial. This study aims to determine the impact of PORT on the disease-free survival (DFS) of stage II thymomas. We retrospectively collected the clinical and oncologic data [age, sex, myasthenia gravis (MG) prevalence, Masaoka-Koga stage, World Health Organization (WHO) histologic subtype] of those patients who underwent radical exeresis in our Unit between January 2000 and December 2020. Kaplan-Meier estimates of DFS were then performed. Our study included 195 patients (M/F = 98/97). Almost all patients were affected by MG (90.7%) and most of them were operated by median sternotomy (93.3%). Thymoma stage was IIa in 87 cases (44.6%) and IIb in 108 cases (55.4%). The most represented histologic subtype was AB (27.7%), followed by B2 (24.6%), A (19%), B1 (14.9%) and B3 (13.8%). PORT was performed in 113 patients (58%, 39 stage IIa and 74 stage IIb). During the surveillance, 8 patients (4.1%) presented pleural recurrences and no local relapses. DFS was comparable in stage IIa and IIb patients, independently from PORT administration (p = .395 and p = .858, respectively). Moreover, PORT did not affect DFS considering the histologic subtypes (p = .304 for A and AB thymomas, p = .608 for B1, B2 and B3 thymomas). In our wide series, PORT administration didn't show any additional benefit on DFS. Therefore, based on our experience, patients with stage II thymoma who underwent radical surgery should not undergo any local adjuvant treatment.

Self-image, self-esteem, anxiety, and functional capacity in patients undergoing open-structure rhinoplasty.

BACKGROUND: Rhinoplasty may improve negative psychological aspects, such as mild to moderate body dysmorphic disorder; however, the repercussions on the self-image and quality of life of patients after the procedure are unknown. OBJECTIVE: To evaluate self-image, self-esteem, anxiety, and functional capacity of patients undergoing open-structure rhinoplasty. METHODS: A primary, analytical, clinical, longitudinal, and prospective study was conducted, which included 30 female patients, aged between 18 and 50 years with elongated nose and nasal hump, who underwent open and structured rhinoplasty. All procedures were performed by a team from the Rhinology DCP/Unifesp. The Rosenberg Self-Esteem Scale - EPM, BDSS, BDD-YBOCS, SF-36, SRQ-20, and STAI (T/E) questionnaires were administered before the surgery and at 6, 12, and 18 months after surgery. RESULTS: The results showed statistically significant differences in the Rosenberg scale - EPM (p = 0.017), BDSS (p < 0.001), BDD (p = 0.006), SF-36 (p = 0.041), SRQ-20 (p = 0.012), and STAI-T (p = 0.001) scores in general analyses. Additionally, the statistically significant changes persisted in various stratified postoperative periods. In the qualitative analysis, there was only statistical significance for the classification of the BDSS score, where the "Absent" (absence of body dysmorphism) index increased from 70.0% in the preoperative state to 96.7% in 18 months postoperatively. The "Present" (presence of body dysmorphism) index fell from 30.0% to 3.3% in the same period (p = 0.001). CONCLUSION: Open-structure rhinoplasty improved the patients' self-image, self-esteem, anxiety, and mental health.

Prospective Evaluation of Extubation Failure in Neonates and Infants After Cardiac Surgery.

Background: Extubation failure and its associated complications are not uncommon after pediatric cardiac surgery, especially in neonates and young infants. We aimed to identify the frequency, etiologies, and clinical characteristics associated with extubation failure after cardiac surgery in neonates and young infants. Methods: We conducted a single center prospective observational study of patients ≤180 days undergoing cardiac surgery between June 2022 and May 2023 with at least one extubation attempt. Patients who failed extubation, defined as reintubation within 72 h of first extubation attempt, were compared with patients extubated successfully using χ2, Fisher exact, or Wilcoxon rank-sum tests as appropriate. Results: We prospectively enrolled 132 patients who met inclusion criteria, of which 11 (8.3%) failed extubation. Median time to reintubation was 25.5 h (range 0.4-55.8). Extubation failures occurring within 12 h (n = 4) were attributed to upper airway obstruction or apnea, whereas extubation failures occurring between 12 and 72 h (n = 7) were more likely to be due to intrinsic lung disease or cardiac dysfunction. Underlying genetic anomalies, greater weight relative to baseline at extubation, or receiving positive end expiratory pressure (PEEP) > 5 cmH2O at extubation were significantly associated with extubation failure. Conclusions: In this study of neonates and young infants recovering from cardiac surgery, etiologies of early versus later extubation failure involved different pathophysiology. We also identified weight relative to baseline and PEEP at extubation as possible modifiable targets for future investigations of extubation failure in this patient population.

Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial.

OBJECTIVE: Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT. METHODS: A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded. RESULTS: Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05). CONCLUSION: Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.

Postoperative pain after parotid surgery-comparison between superficial/total parotidectomy and extracapsular dissection: a prospective observational study.

PURPOSE: To evaluate postoperative pain and discomfort after parotid surgery with regard to different surgical approaches. METHODS: This clinical study was carried out at a single tertiary referral center (2021-2022) and included 2 groups of adult patients (mean age 56.6 ± 12.7 vs. 53.4 ± 14.1 years) following elective parotid surgery due to a parotid tumor of any entity. The first group (SP/TP group) consisted of 31 patients after superficial parotidectomy (SP) or total parotidectomy (TP) (n = 31). The second group (ECD group) included all patients who had undergone extracapsular dissection (ECD) (n = 51). Primary endpoints comprised pain on ambulation as well as maximum and minimum pain (NRS 0-10) on the first three postoperative days (PODs). A neuropathic pain component (evaluated on POD 1 and 3), the analgesic score (collected from the patient file on POD 1-3), treatment-related side-effects/pain-associated impairments, and patient satisfaction (all measured on the 1st POD) were defined as secondary endpoints. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire and the painDETECT® questionnaire. Comparisons were performed using independent t tests, Wilcoxon tests, and χ2 tests, and the respective effect sizes were calculated. RESULTS: Looking at the first postoperative day, patients of both groups (SP/TP vs. ECD) reported comparable pain on ambulation (2.8 ± 2.0 vs. 2.6 ± 1.8; p = 0.628, r = 0.063), maximum (3.5 ± 2.2 vs. 3.5 ± 2.3; p = 0.992, r = 0.002) and minimum pain (1.1 ± 1.04 vs. 1.0 ± 1.2; p = 0.206, r = 0.157). Furthermore, there were no significant differences in pain-related restrictions or pain medication requirement. The patients in both groups were equally satisfied with their pain therapy (p = 0.282, R = 0.135). The sum score of the painDETECT® questionnaire delivered clearly negative (< 12) results on average (POD1: 6.81; POD3: 6.59); no significant difference between the groups was found (p = 0.991, R2 < .001). CONCLUSION: Neither surgical technique on the parotid gland was significantly superior to the other in terms of postoperative pain perception. Overall, postoperative pain can be classified as mild to moderate following parotid surgery. A neuropathic pain component could be excluded for the acute postoperative phase. TRIAL REGISTRATION: The study was registered in the German Registry for Clinical Studies (DRKS) (application No.: DRKS00016520).

Postoperative Pain Comparison Between Alcohol-Assisted and Transepithelial Photorefractive Keratectomy Using Nepafenac Treatment: A Novel Study.

INTRODUCTION: The study aimed to compare postoperative pain between alcohol-assisted and transepithelial photorefractive keratectomy in patients who received the novel analgesic preoperative nepafenac treatment 2 days preoperatively and 3 days postoperatively. Pain, stinging, tearing, light sensitivity, and stress levels were evaluated. METHODS: The study included a retrospective analysis of 55 patients divided into two groups: bilateral alcohol-assisted photorefractive keratectomy (aa-PRK) and transepithelial photorefractive keratectomy (transepithelial-PRK). Nepafenac was administered for pain control for all patients, with patients receiving four drops for 2 days before the surgery and 3 days postoperatively per clinical instructions. Patients completed questionnaires on the day of the surgery and for the first 5 days postoperatively. Statistical analysis was performed using XLSTAT (version 2023.1.2). t-Test was used to analyze and compare pain and symptom levels and Fisher's exact test for categorical data. p-Values less than 0.05 were considered statistically significant. RESULTS: The study examined 55 patients (49% female) with a mean age of 25.11 ± 6.81 years who had undergone bilateral surface refractive surgery to correct myopic errors. The mean baseline standard error (SE) was -3.16 ± 2.20 D. Among these patients, 27 patients underwent aa-PRK and 28 patients underwent transepithelial-PRK. Higher levels of pain were significant in the aa-PRK group (p = 0.003). However, there was no significant difference between the groups in the average levels of stinging, tearing, or light sensation. Additionally, stress levels decreased over time in both groups, with levels becoming almost equal after 5 days, and there was no significant difference in the average stress levels between the two groups. CONCLUSIONS: The study found that patients who underwent the transepithelial-PRK procedure had significantly lower pain levels compared with those who underwent aa-PRK after being treated with nepafenac per protocol. However, there was no significant difference between the two groups in terms of stinging, tearing, light sensation, and stress levels.

Protocol for a feasibility multi-centre randomised controlled trial of a pre-operative two-week very low-calorie diet to reduce steatosis prior to liver resection (RESOLVE).

BACKGROUND: Hepatic steatosis (HS) increases morbidity and mortality associated with liver surgery (LS). Furthermore, patients with HS are more likely to require a blood transfusion, which is associated with worse short and long-term outcomes. Patients with HS requiring LS receive no specific dietary treatment or advice. A very low-calorie diet (VLCD) is commonly used before gallbladder and bariatric surgery to reduce liver volumes and associated intraoperative morbidity. These diets typically provide 800-1200 kcal/day over a 2-4-week period. Limited evidence suggests that a VLCD in patients with LS may result in better outcomes. METHODS: This study aims to test the feasibility of delivering a multi-centre randomised clinical trial to compare a dietary intervention (VLCD plus motivational instructions) versus treatment as usual (TAU) in people with HS having LS. This study will provide high-quality data to estimate screening rates, recruitment, randomisation, retention, and intervention adherence. The study will also determine the definitive trial's most clinically relevant primary outcome. The study will also estimate resource use and costs associated with the delivery of the intervention. Seventy-two adults ≥ 18 who are scheduled to undergo elective LS and have a magnetic resonance imaging (MRI) identified HS will be recruited. Acceptability to the dietary intervention will be evaluated with food diaries and focus groups. Clinical and patient-reported outcomes will be collected at baseline, pre- and post-surgery, day of discharge, plus 30- and 90-day follow-up. DISCUSSION: This feasibility study will provide data on the acceptability and feasibility of a dietary intervention for patients with HS having LS. The intervention has been developed based on scientific evidence from other clinical areas and patient experience; therefore, it is safe for this patient group. Patients with experience of LS and VLCDs have advised throughout the development of the study protocol. The findings will inform the design of a future definitive study. TRIAL REGISTRATION: ISRCTN Number 19701345. Date registered: 20/03/2023. URL: https://www.isrctn.com/ISRCTN19701345 .

MEF2C Alleviates Postoperative Cognitive Dysfunction by Repressing Ferroptosis.

BACKGROUND: Ferroptosis, a form of programmed cell death featured by lipid peroxidation, has been proposed as a potential etiology for postoperative cognitive dysfunction (POCD). Myocyte-specific enhancer factor 2C (MEF2C), a transcription factor expressed in various brain cell types, has been implicated in cognitive disorders. This study sought to ascertain whether MEF2C governs postoperative cognitive capacity by affecting ferroptosis. METHODS: Transcriptomic analysis of public data was used to identify MEF2C as a candidate differentially expressed gene in the hippocampus of POCD mice. The POCD mouse model was established via aseptic laparotomy under isoflurane anesthesia after treatment with recombinant adeno-associated virus 9 (AAV9)-mediated overexpression of MEF2C and/or the glutathione peroxidase 4 (GPX4) inhibitor RSL3. Cognitive performance, Nissl staining, and ferroptosis-related parameters were assessed. Dual-luciferase reporter gene assays and chromatin immunoprecipitation assays were implemented to elucidate the mechanism by which MEF2C transcriptionally activates GPX4. RESULTS: MEF2C mRNA and protein levels decreased in the mouse hippocampus following anesthesia and surgery. MEF2C overexpression ameliorated postoperative memory decline, hindered lipid peroxidation and iron accumulation, and enhanced antioxidant capacity, which were reversed by RSL3. Additionally, MEF2C was found to directly bind to the Gpx4 promoter and activate its transcription. CONCLUSIONS: Our findings suggest that MEF2C may be a promising therapeutic target for POCD through its negative modulation of ferroptosis.

Postoperative delirium: A tragedy for elderly cancer patients.

In this editorial, we comment on the article by Hu et al entitled "Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique". We wanted to draw attention to the general features of postoperative delirium (POD) as well as the areas where there are uncertainties and contradictions. POD can be defined as acute neurocognitive dysfunction that occurs in the first week after surgery. It is a severe postoperative complication, especially for elderly oncology patients. Although the underlying pathophysiological mechanism is not fully understood, various neuroinflammatory mechanisms and neurotransmitters are thought to be involved. Various assessment scales and diagnostic methods have been proposed for the early diagnosis of POD. As delirium is considered a preventable clinical entity in about half of the cases, various early prediction models developed with the support of machine learning have recently become a hot scientific topic. Unfortunately, a model with high sensitivity and specificity for the prediction of POD has not yet been reported. This situation reveals that all health personnel who provide health care services to elderly patients should approach patients with a high level of awareness in the perioperative period regarding POD.

Predictive modeling for post operative delirium in elderly.

Delirium, a complex neurocognitive syndrome, frequently emerges following surgery, presenting diverse manifestations and considerable obstacles, especially among the elderly. This editorial delves into the intricate phenomenon of postoperative delirium (POD), shedding light on a study that explores POD in elderly individuals undergoing abdominal malignancy surgery. The study examines pathophysiology and predictive determinants, offering valuable insights into this challenging clinical scenario. Employing the synthetic minority oversampling technique, a predictive model is developed, incorporating critical risk factors such as comorbidity index, anesthesia grade, and surgical duration. There is an urgent need for accurate risk factor identification to mitigate POD incidence. While specific to elderly patients with abdominal malignancies, the findings contribute significantly to understanding delirium pathophysiology and prediction. Further research is warranted to establish standardized predictive for enhanced generalizability.