Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients.

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Is the visual impairment a risk factor for frailty in older adults? A systematic review and meta-analysis of 10-year clinical studies.

BACKGROUND: Frailty is linked to poor health outcomes later in life. Recent research suggests that visual loss is a possible modifiable risk factor for frailty. AIMS: To analyze the relationship between visual impairment (VI) and frailty and investigate whether it can increase the risk of frailty in older adults. METHODS: We performed a systematic review and meta-analysis of cohort studies following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We systematically searched PubMed, Embase, and Scopus databases for relevant studies published between 2012 and 2022 that clearly described VI and frailty measurement methods. Cross-sectional and longitudinal studies that examined the associations between VI and the existence of frailty in adults aged 65 years or older were synthesized. Meta-analyses were conducted using the measurement of risk and a 95% confidence interval for each study. Quality assessment using the Newcastle-Ottawa Scale (NOS), risk of bias, heterogeneity, and sensitivity analyses were also conducted. RESULTS: Our search identified 1074 manuscripts published in the English language between 1 January 2012 and 9 June 2022. After studies screening, seventeen articles, including 22,192 participants and 3624 cases of frailty, were selected. A random-effect meta-analysis demonstrated a significant association between visual impairment and the risk of frailty (OR 2.13; 95% CI 1.67-2.72). The quality rating of the cross-sectional studies averaged 8.33 (95% CI 7.77-8.89) of the maximum score on the NOS. CONCLUSIONS: Visual impairment increases the risk of frailty in later life and should be accurately assessed in frail older adults.

Viscoelastic versus conventional coagulation tests to reduce blood product transfusion in patients undergoing liver transplantation: A systematic review and meta-analysis.

BACKGROUND: Recent literature suggests viscoelastic test (VET)-guided transfusion management could be associated with reduced blood product administration in patients undergoing liver transplantation. OBJECTIVES: To assess the effectiveness of coagulation management guided by VETs compared with conventional coagulation tests (CCTs) in reducing blood product transfusion in patients undergoing liver transplantation. DESIGN: Systematic review and meta-analysis of randomised (RCTs) and nonrandomised clinical trials performed according to PRISMA guidelines. The protocol was previously published (PROSPERO: CRD42021230213). DATA SOURCES: The Cochrane Central Library, PubMed/MEDLINE, Embase and the Transfusion Evidence Library were searched up to 30 th January 2022. ELIGIBILITY CRITERIA: Setting: operating room. Patients: liver transplantation recipients. Intervention: use of VETs versus CCTs. Main outcome measures: the primary outcome was the mean number of transfused units for each blood product including red blood cells (RBCs), fresh frozen plasma (FFP), platelets (PLTs) and cryoprecipitate. Secondary outcomes included mortality rate, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Seventeen studies ( n  = 5345 patients), 15 observational and two RCTs, were included in this review. There was a mean difference reduction in RBCs [mean difference: -1.40, 95% confidence interval (95% CI), -1.87 to -0.92; P  < 0.001, I2  = 61%) and FFP units (mean difference: -2.98, 95% CI, -4.61 to -1.35; P  =  < 0.001; I2  = 98%) transfused in the VETs group compared with the CCTs one. A greater amount of cryoprecipitate was administered in the VETs group (mean difference: 2.71, 95% CI, 0.84 to 4.58; P  = 0.005; I2  = 91%). There was no significant difference in the mean number of PLT units, mortality, hospital and ICU-LOS. CONCLUSION: Our meta-analysis demonstrated that VETs implementation was associated with reduced RBC and FFP consumption in liver transplantation patients without effects on mortality and hospital and ICU-LOS. The certainty of evidence ranged from moderate to very low. Further well conducted RCTs are needed to improve the certainty of evidence.

How attachment style, mentalization and preparedness for death are associated with pre-loss grief symptoms' severity: A network analysis study in caregivers of terminally ill cancer patients.

Several psychological dimensions influence the psychological adjustment of terminally ill cancer patients' caregivers, during the end-of-life phase. The present study explored the associations between attachment styles, mentalization, preparedness for death, and the severity of pre-loss grief symptoms in 102 caregivers of terminal cancer patients. The results of the network analysis showed that insecure attachment dimensions were positively associated with several central pre-loss grief symptoms. Mentalization and preparedness for death showed negative associations with several pre-loss grief symptoms. Interestingly, bitterness showed a negative association with need for approval and a positive association with mentalization. The results provided insight into the grieving process for palliative care providers to implement effective caregiver support interventions.

Will I or my loved one die? Concordant awareness between terminal cancer patients and their caregivers is associated with lower patient anxiety and caregiver burden.

OBJECTIVE: The aims of this study were to investigate the association between patients' awareness of their terminal illness and the levels of anxiety and depression, whether the concordance between the patients' and caregivers' belief about the patient's terminal illness was associated with patient's anxiety and depression, and with the caregiver burden. METHOD: The study recruited 31 terminally ill patients with cancer along with their caregivers from a Palliative Care Unit. All data about patients and caregivers' awareness of the illness, patients' depression and anxiety, and caregiver burden were collected. RESULTS: Patients aware of their short-term prognosis of death showed lower levels of anxiety than the unaware ones, especially women. Aware patients with concordant caregivers showed lower levels of anxiety but not of depression. Caregivers concordant with the patients' awareness presented lower levels of strain and burden. Finally, terminal patients who had an adult child caregiver were less likely to be aware of their terminal condition. CONCLUSIONS: It appears that illness awareness and the caregiver's concordance with the patient's belief on the terminal condition are associated with lower anxiety, especially in women, and a reduced burden for caregivers.

Neural correlates of sex-related differences in attachment dimensions.

The purpose of this study was to investigate sex-related differences in the electrophysiological response to socioemotional stimuli (positive, negative, and ambiguous) depicting couple interactions. The associations between anxiety and avoidance attachment dimensions (measured with the Experiences in Close Relationships-Revised questionnaire) and the strength of cortico-limbic circuit intensity was explored, recorded using a 256-Hydrocel Geodesic Sensor-Net. Event-related potentials (ERPs) and standardized low-resolution electromagnetic tomography (sLORETA) data were analyzed for a total sample of 74 participants. Regression analyses showed that the women presented increased brain intensity compared with that in men, and the avoidance score was positively associated with brain intensity, particularly in response to negative socioemotional stimuli. The interaction sex per avoidance was a significant predictor of intensity in many brain areas, with women displaying significantly more pronounced positive associations between avoidance and brain intensity than men. In conclusion, the findings of the present study showed that women appeared to be more emotionally involved during the socioemotional task. Avoidance was positively associated with intensity of the cingulate and prefrontal regions, and these associations were more pronounced in women than in men. These findings suggested that avoidance seems to represent two different socioemotional strategies, in which women appear to activate an avoidant strategy to modulate increased emotional involvement in relationships, whereas men appear to adopt avoidance with a more intense emotional suppression.

Implementation of frailty preoperative assessment to predict outcome in patients undergoing urological surgery: a systematic review and meta-analysis.

BACKGROUND: A common limit of the widely used risk scores for preoperative assessment is the lack of information about aspects linked to frailty that may affect outcome, especially in the setting of elderly patients undergoing urological surgery. Frailty has recently been introduced as an additional characteristic to be assessed for better identifying patients at risk of negative outcomes. OBJECTIVE: To examine the evidence for recent advances in preoperative assessment in patients undergoing urological surgery focussing on the detrimental effect of frailty on outcome, including major (mPCs) and total postoperative complications (tPCs), discharge to a facility, and mortality. The secondary aim was to establish which cut-off scores of the modified Frailty Index (mFI, 11 items) and/or simplified FI (sFI, five items) predicted PCs. METHODS: We searched PubMed, the Excerpta Medica database (EMBASE), Cochrane Library and clinicaltrial.gov from inception to 31 May 2020. Studies reporting relationships between the investigated outcomes and patients' frailty were included. We estimated odds ratios (ORs) through a random effect model by using Revman 5.4. RESULTS: Frailty, assessed by different tools, was associated with a significantly higher rate of 30-day (OR 1.73, 95% confidence interval [CI] 1.58-1.89) and 90-day (OR 2.09, 95% CI 1.14-3.82) mPCs and 30-day tPCs (OR 2.10, 95% CI 1.76-2.52). A mFI of ≥2 was associated with a higher rate of 30-day mPCs (OR 1.79, 95% CI 1.69-1.89) and greater 30-day mortality (OR 3.46, 95% CI 2.10-5.49). A pre-planned post hoc analysis also revealed that a sFI of ≥3 was predictive of mPCs (OR 3.30, 95% CI 2.12-5.12). CONCLUSIONS: Frailty assessment may help to predict PCs and mortality in patients undergoing major urological surgery. Either a mFi of ≥2 or sFI of ≥3 should be considered potential 'red flags' for preoperative risk assessment and decision-making. There is not enough evidence to confirm the necessity to perform frailty assessment in minor urological surgery.

Preoperative psychological characteristics affecting mid-term outcome after bariatric surgery: a follow-up study.

BACKGROUND: The purpose of this study was to investigate the relationship between preoperative psychological factors and percentage of total weight loss (%TWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) to identify possible psychological therapy targets to improve the outcome of bariatric surgery. METHODS: Seventy-six patients completed the Hamilton's Anxiety and Depression Scales (HAM-A, HAM-D) and Toronto Alexithymia Scale (TAS-20) the day before surgery (T0). The pre-operative body weight and the %TWL at 3 (T1), 6 (T2), and 24-30 (T3) months were collected. RESULTS: At T3, depressed and alexithymic patients showed a lower %TWL compared to non-depressed patients (p = 0.03) and to non-alexithymic patients (p = 0.02), respectively. Finally, patients who had at least one of the three analyzed psychological factors showed less weight loss, at T2 (p = 0.02) and T3 (p = 0.0004). CONCLUSIONS: Psychological factors may also affect long-term outcome of bariatric surgery. This study shows an association between alexithymia/depression pre-operative levels and the weight loss at 30 months'follow-up after bariatric surgery. LEVEL OF EVIDENCE: Level III, longitudinal cohort study.

Correction to: Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

The article Perioperative Management of Elderly patients (PriME).

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

BACKGROUND: Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS: To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS: A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS: A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS: These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Cognitive decline after carotid endarterectomy: Systematic review and meta-analysis.

BACKGROUND: Postoperative cognitive decline (pCD) occurs frequently (6 to 30%) after carotid endarterectomy (CEA), although there are no exact estimates and risk factors are still unclear. OBJECTIVE: The objective of this study was to determine pCD incidence and risk factors in CEA patients. DESIGN: We performed a systematic review and meta-analysis of both randomised and nonrandomised trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: We searched Cochrane, PubMed/Medline and Embase databases from the date of database inception to 1 December 2018. ELIGIBILITY CRITERIA: We selected longitudinal studies including CEA patients with both pre-operative and postoperative cognitive assessments. Primary outcome was pCD incidence, differentiating delayed neurocognitive recovery (dNCR) and postoperative neurocognitive disorder (pNCD). dNCR and pNCD incidences were expressed as proportions of cases on total CEA sample and pooled as weighted estimates from proportions. Postoperative delirium was excluded from the study design. Secondary outcomes were patient-related (i.e. age, sex, diabetes, hypertension, contralateral stenosis, pre-operative symptoms, dyslipidaemia and statin use) and procedure-related (i.e. hyperperfusion, cross-clamping duration and shunting placement) risk factors for pCD. We estimated odds ratios (ORs) and mean differences through a random effects model by using STATA 13.1 and RevMan 5.3. RESULTS: Our search identified 5311 publications and 60 studies met inclusion criteria reporting a total of 4823 CEA patients. dNCR and pNCD incidence were 20.5% [95% confidence interval (CI), 17.1 to 24.0] and 14.1% (95% CI, 9.5 to 18.6), respectively. pCD risk was higher in patients experiencing hyperperfusion during surgery (OR, 35.68; 95% CI, 16.64 to 76.51; P < 0.00001; I = 0%), whereas dNCR risk was lower in patients taking statins before surgery (OR, 0.56; 95% CI, 0.41 to 0.77; P = 0.0004; I = 19%). Sensitivity analysis revealed that longer cross-clamping duration was a predictor for dNCR (mean difference, 5.25 min; 95% CI, 0.87 to 9.63; P = 0.02; I = 49%). CONCLUSION: We found high incidences of dNCR (20.5%) and pNCD (14.1%) after CEA. Hyperperfusion seems to be a risk factor for pCD, whereas the use of statins is associated with a lower risk of dNCR. An increased cross-clamping duration could be a risk factor for dNCR. TRIAL REGISTRATION: This systematic review was registered in the International Prospective Register of Systematic Reviews (CDR42017073633).

Violence in video game produces a lower activation of limbic and temporal areas in response to social inclusion images.

Exposure to violence in video games has been associated with a desensitization toward violent content, a decrease of empathy, and prosocial behavior. Moreover, violent video games seem to be related to a reduction of neural activation in the circuits linked to social emotional processing. The purpose of the present study was to compare the neural response to social inclusion images after violent and nonviolent video game playing. Electroencephalographic data of the 32 participants were recorded during a visual task with three presentations (T0, T1, T2) of 60 stimuli (30 social inclusion vs. 30 neutral images). After the T0 presentation, the participants played with a video game (orientation or violent). After the T1 presentation, the participants played with the other video game (orientation or violent). The two types of video games were randomly displayed. Event-related potential (ERP) components and low-resolution electromagnetic tomography (sLORETA) were analyzed. The main findings showed a longer latency of the P2 component on occipito-temporal montage and a lower activation of the limbic and temporal areas in response to the social inclusion images post violent video game compared with the post orientation video game. The findings suggest a reduction of emotional engagement in social processing after playing violent video game.

Alexithymia and weight loss in obese patients underwent laparoscopic sleeve gastrectomy.

PURPOSE: Obesity is a multifactorial disease characterized by genetic, social, cultural and psychological factors. Currently, bariatric surgery represents the gold-standard intervention to treat morbid obesity in order to counteract associated disabling comorbidities. Several studies showed correlation between post-surgery weight loss and psychological factors. Also, the alexithymia may have a role in affecting post-surgery outcomes in bariatric patients, even if there are no studies investigating its role at 12-month follow-up. The purpose of the present study was to investigate the association between alexithymia and the postoperative weight loss 12 months after laparoscopic sleeve gastrectomy. METHODS: Seventy-five patients undergoing laparoscopic sleeve gastrectomy were enrolled. The Toronto Alexithymia Scale (TAS-20) was administered to patients. A postoperative weight loss check was performed at 3 and then 12 months after surgery. RESULTS: The TAS-20 total score was negatively correlated with the percent of excess weight loss (%EWL) at the 12-month follow-up (r = -0.24; p = 0.040). The analysis showed that non-alexithymic patients had a greater weight loss at 12 months after surgery compared to both probably alexithymics (71.88 ± 18.21 vs. 60.7 ± 12.5; p = 0.047) and probably alexithymic patients (71.88 ± 18.21 vs. 56 ± 22.8; p = 0.007). The preoperative BMI was a significant covariate [F(1,70) = 6.13 (p = 0.016)]. CONCLUSION: In the present study, the patients with higher preoperative BMI and identified as alexithymic showed lower %EWL at 12 months after laparoscopic sleeve gastrectomy. Findings point out the importance to take into consideration possible psychological treatments focused on improving emotional regulations of patients who are seeking bariatric surgery.

Goal-directed hemodynamic management in patients undergoing primary debulking gynaecological surgery: A matched-controlled precision medicine study.

BACKGROUND: Usefulness of intraoperative goal-directed hemodynamic management (GDHM) for patients without comorbidities is debated. After clinical implementation of a pulse contour analysis-guided GDHM protocol, which foresees early vasopressor use for recruiting unstressed volume, we conducted a matched-controlled analysis to explore its impact on the amount of fluids intraoperatively administered to patients without comorbidities who underwent extended abdominal surgery for ovarian cancer. METHODS: After 1:1 matching accounting for body mass index, oncologic disease severity and intraoperative blood losses, 22 patients treated according to this GDHM protocol were compared to a control group of 22 patients who had been managed according to the clinical decision of attending physicians, taken without advanced monitoring. Results are displayed as median[interquartile range]. RESULTS: All analyzed patients underwent radical hysterectomy, bilateral adnexectomy, bowel resection, peritonectomy and extended pelvic/periaortic lymphadenectomy; median length of surgery was 517[480-605] min in patients receiving GDHM and 507[480-600] min in control group. Intraoperatively, patients undergoing GDHM received less fluids (crystalloids 2950[2700-3300] vs. 5150[4700-6000] mL, p < 0.001; colloids 100[50-200] vs. 750[500-1000] mL, p < 0.001) and showed a trend to more frequent vasopressor administration (32 vs 9%, p = 0.13). Greater intraoperative diuresis (540[480-620] mL vs. 450[400-500] mL, p = 0.007), lower blood lactates at surgery end (1.5[1.1-2] vs. 4.1[3.3-5] mmol/L, p < 0.001), shorter time to bowel function recovery (1 [1, 2] vs. 4 [3-5] days, p < 0.001) and hospital discharge (7 [6-8] vs 12 [9-16] days, p < 0.0001) were detected in patients receiving GDHM. CONCLUSIONS: In high-tumor load gynaecological patients without comorbidities who receive radical and prolonged surgery, intraoperative use of this novel GDHM protocol helped limit fluids administration with safety.

Neurophysiological Correlates of Collective Trauma Recall in 2009 L'Aquila Earthquake Survivors.

In the present study, we aimed to explore neural correlates of survivors of the 2009 L'Aquila, Italy earthquake in response to being shown pictures featuring their own city before and after an earthquake as well as those of an unfamiliar city. Moreover, we explored the associations among psychological variables and brain responses to the pictures of L'Aquila after the earthquake. Our final sample (N = 30 adults) comprised 15 survivors (M age = 31.40 years, SD = 9.42) and 15 controls (M age = 30.53 years, SD = 10.01). Participants' electroencephalographic (EEG) data were recorded during a visual task that included earthquake-related stimuli. Participants were assessed for posttraumatic and dissociation symptoms and event-related potential components, and low-resolution electromagnetic tomography (sLORETA) were analyzed. Compared to the control group, source localization in survivors indicated a lower intensity of the amygdala, hippocampal, parahippocampal, and temporopolar areas in response to visual stimuli concerning the earthquake, p < .001 to p < .0001. Results indicated a reduced limbic activation in response to visual stimuli that evoked the recall of earthquake in survivors. This finding suggests that survivors likely adopted a distancing strategy toward stimuli that may have elicited an emotional activation related to collective trauma.

Sharing information about cancer with one's family is associated with improved quality of life.

OBJECTIVE: The aim of this study was to investigate the association between cancer patients' ability to share information about their illness with their social network and attachment style dimensions, alexithymia, and quality of life. We hypothesised that ability to share information about one's cancer with family, friends, and medical teams would be positively associated with quality of life and secure attachment and negatively associated with alexithymia. METHODS: Forty-five cancer patients were recruited from the Psycho-oncology Unit of the San Camillo-Forlanini Hospital in Rome. We collected anamnestic data and self-report data on social sharing ability, quality of life, alexithymia, and attachment. RESULTS: Sharing with family (B = 4.66; SE = 1.82; ß = .52; SE = 0.20; t(41) = 2.6; P = .0143) was the only predictor of global health status, and attachment security was the only predictor of mean social sharing (B = 0.25; SE = 0.06; ß = .63; SE = 0.14; t(41) = 4.4; P < .0001). CONCLUSIONS: Encouraging patients to share information about their experience of cancer may help to improve their quality of life. Attachment security seems to promote social sharing. Psychological assessments of cancer patients should cover both ability to share information about one's cancer with family and attachment security.

Emotional management and biological markers of dietetic regimen in chronic kidney disease patients.

The aim of the study was to investigate the association between psychological characteristics and biological markers of adherence in chronic kidney disease patients receiving conservative therapy, hemodialysis, peritoneal dialysis (PD), or kidney transplantation. Seventy-nine adult patients were asked to complete the following questionnaires: Toronto Alexithymia scale, Snaith-Hamilton Pleasure Scale, and Short Form Health Survey. Biological markers of adherence to treatment were measured. Peritoneal dialysis patients showed a lower capacity to feel pleasure from sensorial experience (p = .011) and a higher values of phosphorus compared to the other patients' groups (p = .0001). The inability to communicate emotions was negatively correlated with hemoglobin levels (r = -(0).69; p = .001) and positively correlated with phosphorus values in the PD patients (r = .45; p = .050). Findings showed higher psychological impairments and a lower adherence to the treatment in PD patients and suggest the implication of emotional competence in adherence to treatment.

Persistent complex bereavement disorder in caregivers of terminally ill patients undergoing supportive-expressive treatment: a pilot study.

BACKGROUND: The proposal of persistent complex bereavement disorder (PCBD) in the DSM-V increased the interest on the impact of grief on the psychological health. AIMS: Investigating the time course of psychological symptoms, emotional and social abilities in caregivers (undergoing or not to supportive-expressive treatment) of terminally ill cancer patients from 1 months before loss to 14 months after it. METHOD: Thirty-three of 60 caregivers were assessed by PG-12, HAM-A, HAM-D, TAS-20 and ASQ, at the admission in Hospice, and after 3, 10 and 14 months from the loss. Twelve caregivers adhered to follow a supportive-expressive treatment and 21 caregivers did not. RESULTS: PG-12, anxiety, and depression scores decreased in both groups over time. The score of difficulty in identifying emotions and confidence with closeness decreased significantly only in the treated-group. PG-12 score at T0 was able to predict the DSM V diagnosis of PCBD at T3. CONCLUSIONS: Findings showed a decrease of the anxiety, depression, security in the attachment style and an increase of the ability to identify emotions during the first year after loss in caregivers of terminally ill cancer patients. Pre-loss assessment of prolonged grief risk seems useful to predict the diagnosis of PCBD 1 year after loss.