Multicenter cohort study on the presentation and treatment of acute appendicitis during the COVID-19 pandemic.

PURPOSE: Current studies have demonstrated conflicting results regarding surgical care for acute appendicitis during the COVID-19 pandemic. This study aimed to assess trends in diagnosis as well as treatment of acute appendicitis in the Netherlands during the first and second COVID-19 infection wave. METHODS: All consecutive patients that had an appendectomy for acute appendicitis in nine hospitals from January 2019 to December 2020 were included. The primary outcome was the number of appendectomies for acute appendicitis. Secondary outcomes included time between onset of symptoms and hospital admission, proportion of complex appendicitis, postoperative length of stay and postoperative infectious complications. Outcomes were compared between the pre-COVID group and COVID group. RESULTS: A total of 4401 patients were included. The mean weekly rate of appendectomies during the COVID period was 44.0, compared to 40.9 in the pre-COVID period. The proportion of patients with complex appendicitis and mean postoperative length of stay in days were similar in the pre-COVID and COVID group (respectively 35.5% vs 36.8%, p = 0.36 and 2.0 ± 2.2 vs 2.0 ± 2.6, p = 0.93). There were no differences in postoperative infectious complications. A computed tomography scan was used more frequently as a diagnostic tool after the onset of COVID-19 compared to pre-COVID (13.8% vs 9.8%, p < 0.001, respectively). CONCLUSION: No differences were observed in number of appendectomies, proportion of complex appendicitis, postoperative length of stay or postoperative infectious complications before and during the COVID-19 pandemic. A CT scan was used more frequently during the COVID-19 pandemic.

Perception of auditory stimuli during general anesthesia and its effects on patient outcomes: a systematic review and meta-analysis.

PURPOSE: Interest in implicit memory formation and unconscious auditory stimulus perception during general anesthesia has resurfaced as perioperative music has been reported to produce beneficial effects. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating explicit and implicit memory formation during general anesthesia and its effects on postoperative patient outcomes and recovery. SOURCE: We performed a systematic literature search of Embase, Ovid Medline, and Cochrane Central from inception date until 15 October 2020. Eligible for inclusion were RCTs investigating intraoperative auditory stimulation in adult surgical patients under general anesthesia in which patients, healthcare staff, and outcome assessors were all blinded. We used random effects models for meta-analyses. This study adhered to the PRISMA guidelines and was registered in PROSPERO (CRD42020178087). PRINCIPAL FINDINGS: Fifty-three (4,200 patients) of 5,859 identified articles were included. There was evidence of implicit memory formation in seven out of 17 studies (41%) when assessed using perceptual priming tasks. Mixed results were observed on postoperative behavioural and motor response after intraoperative suggestions. Intraoperative music significantly reduced postoperative pain (standardized mean difference [SMD], -0.84; 95% confidence interval [CI], -1.1 to -0.57; P < 0.001; I2 = 0; n = 226) and opioid requirements (SMD, -0.29; 95% CI, -0.57 to -0.015; P = 0.039; I2 = 36; n = 336), while positive therapeutic suggestions did not. CONCLUSION: The results of this systematic review and meta-analysis show that intraoperative auditory stimuli can be perceived and processed during clinically adequate, general anesthesia irrespective of surgical procedure severity, leading to implicit memory formation without explicit awareness. Intraoperative music can exert significant beneficial effects on postoperative pain and opioid requirements. Whether the employed intraoperative anesthesia regimen is of influence is not yet clear.

RéSUMé: OBJECTIF: L'intérêt pour la création de mémoire implicite et la perception inconsciente de stimuli auditifs pendant l'anesthésie générale a refait surface depuis qu'il a été rapporté que l'audition de musique périopératoire produisait des effets bénéfiques. Nous avons mené une revue systématique et une méta-analyse des études randomisées contrôlées (ERC) évaluant la création de mémoire explicite et implicite pendant l'anesthésie générale et ses effets sur les devenirs postopératoires et le rétablissement des patients. SOURCES: Nous avons effectué une recherche documentaire systématique dans les bases de données Embase, Ovid Medline et Cochrane Central depuis leur date de création jusqu'au 15 octobre 2020. Étaient admissibles à l'inclusion les ERC évaluant la stimulation auditive peropératoire chez les patients chirurgicaux adultes sous anesthésie générale, dans lesquelles les patients, le personnel de soins de santé et les évaluateurs des devenirs étaient tous en aveugle. Nous avons utilisé des modèles à effets aléatoires pour les méta-analyses. Cette étude a respecté les lignes directrices PRISMA et a été enregistrée dans le registre PROSPERO (CRD42020178087). CONSTATATIONS PRINCIPALES: Cinquante-trois des 5859 articles identifiés (4200 patients) ont été inclus. Sept études sur 17 (41 %) comportaient des données probantes concernant la création de mémoire implicite lorsqu'elle était évaluée à l'aide de tâches d'amorçage perceptif. Des résultats mitigés ont été observés sur la réponse comportementale et motrice postopératoire après des suggestions peropératoires. La musique peropératoire a considérablement réduit la douleur postopératoire (différence moyenne standardisée [DMS], -0,84; intervalle de confiance [IC] de 95 %, -1,1 à -0,57; P < 0,001; I2 = 0; n = 226) et les besoins en opioïdes (DMS, -0,29; IC 95 %, -0,57 à -0,015; P = 0,039; I2 = 36; n = 336), mais pas les suggestions thérapeutiques positives. CONCLUSION: Les résultats de cette revue systématique et méta-analyse montrent que les stimuli auditifs peropératoires peuvent être perçus et traités pendant une anesthésie générale cliniquement adéquate, indépendamment de la gravité de l'intervention chirurgicale, menant à la création de mémoire implicite sans conscience explicite. La musique peropératoire peut avoir des effets bénéfiques significatifs sur la douleur postopératoire et les besoins en opioïdes. Il n'est pas encore possible de déterminer si le type d'anesthésie peropératoire utilisé a une influence.

Corticosteroids and other immunosuppressants for immune-related adverse events and checkpoint inhibitor effectiveness in melanoma.

BACKGROUND: Recent studies indicate an association between immunosuppression for immune-related adverse events (irAEs) and impaired survival in patients who received immune checkpoint inhibitors. Whether this is related to corticosteroids or second-line immunosuppressants is unknown. In the largest cohort thus far, we assessed the association of immunosuppressant type and dose with survival in melanoma patients with irAEs. METHODS: Patients with advanced melanoma who received immunosuppressants for irAEs induced by first-line anti-PD-1 ± anti-CTLA-4 were included from 18 hospitals worldwide. Associations of cumulative and peak dose corticosteroids and use of second-line immunosuppression with survival from start of immunosuppression were assessed using multivariable Cox proportional hazard regression. RESULTS: Among 606 patients, 404 had anti-PD-1 + anti-CTLA-4-related irAEs and 202 had anti-PD-1-related irAEs. 425 patients (70 %) received corticosteroids only; 181 patients (30 %) additionally received second-line immunosuppressants. Median PFS and OS from starting immunosuppression were 4.5 (95 %CI 3.4-8.1) and 31 (95 %CI 15-not reached) months in patients who received second-line immunosuppressants, and 11 (95 %CI 9.4-14) and 55 (95 %CI 41-not reached) months in patients who did not. High corticosteroid peak dose was associated with worse PFS and OS (HRadj 1.14; 95 %CI 1.01-1.29; HRadj 1.29; 95 %CI 1.12-1.49 for 80vs40mg), while cumulative dose was not. Second-line immunosuppression was associated with worse PFS (HRadj 1.32; 95 %CI 1.02-1.72) and OS (HRadj 1.34; 95 %CI 0.99-1.82) compared with corticosteroids alone. CONCLUSIONS: High corticosteroid peak dose and second-line immunosuppressants to treat irAEs are both associated with impaired survival. While immunosuppression is indispensable for treatment of severe irAEs, clinicians should weigh possible detrimental effects on survival against potential disadvantages of undertreatment.