Influence of Intraoperative Fluid Management on Postoperative Outcome and Mortality of Cytoreductive Surgery for Advanced Ovarian Cancer-A Retrospective Observational Study.

Background: The surgical treatment of advanced ovarian cancer is associated with extensive tissue trauma, prolonged operating times and a considerable volume shift. It, therefore, represents a challenge for anaesthesiological management. Aim: The aim of this single-centre, retrospective, observational study was to investigate whether intraoperative extensive volume supply influences postoperative outcomes and long-term survival. Methods: The study included 73 patients with a mean (SD) age of 63 (13) years who underwent extensive tumour-reducing surgery for ovarian cancer between 2012 and 2015. The effect of the intraoperative fluid balance on postoperative complications, such as anastomotic insufficiency or pleural effusions, was investigated using logistic regression. Further, the influence of fluid balance, lactate and creatinine levels on 5-year survival was analysed in a Cox regression model. Associations between anaesthesia time and the intraoperative fluid balance were examined using Spearman's rank correlation coefficients. Results: The mean (SD) postoperative fluid balance in the considered patient cohort was 9.1 (3.4) litres (l) at a mean (SD) anaesthesia time of 529 (106) minutes. Cox regression did not reveal a statistically significant effect of the fluid balance, but it did reveal a statistically significant association between the lactate level 24 h following surgery and the 5-year survival (HR [95%-CI] fluid balance: 0.97 [0.85, 1.11]; HR [95%-CI] lactate: 1.79 [1.24, 2.58]). According to logistic regression, the intraoperative fluid balance was associated with an increased chance of postoperative complications in the considered patient cohort (OR [95%-CI] 1.28 [1.1, 1.54]). Conclusions: We could not detect a negative impact of an increased fluid balance on 5-year survival, but a negative impact on postoperative complications was found in our patient cohort.

Pseudo-value regression trees.

This paper presents a semi-parametric modeling technique for estimating the survival function from a set of right-censored time-to-event data. Our method, named pseudo-value regression trees (PRT), is based on the pseudo-value regression framework, modeling individual-specific survival probabilities by computing pseudo-values and relating them to a set of covariates. The standard approach to pseudo-value regression is to fit a main-effects model using generalized estimating equations (GEE). PRT extend this approach by building a multivariate regression tree with pseudo-value outcome and by successively fitting a set of regularized additive models to the data in the nodes of the tree. Due to the combination of tree learning and additive modeling, PRT are able to perform variable selection and to identify relevant interactions between the covariates, thereby addressing several limitations of the standard GEE approach. In addition, PRT include time-dependent effects in the node-wise models. Interpretability of the PRT fits is ensured by controlling the tree depth. Based on the results of two simulation studies, we investigate the properties of the PRT method and compare it to several alternative modeling techniques. Furthermore, we illustrate PRT by analyzing survival in 3,652 patients enrolled for a randomized study on primary invasive breast cancer.

Cognitive-behavioral therapy and acceptance and commitment therapy for anxiety and depression in patients with fibromyalgia: a systematic review and meta-analysis.

Introduction: Defined by chronic, musculoskeletal pain, fibromyalgia is often comorbid with depression and anxiety. In these cases, the first line medical treatment can be successfully combined with psychological interventions. Cognitive-behavioral therapy and acceptance and commitment therapy are among the most widely studied approaches in relation to chronic pain, including fibromyalgia. The objective of this review is to analyze the efficiency of these psychological treatments for alleviating emotional distress in fibromyalgia. Method: The search was conducted on the PubMed, Scopus and Web of Science online databases. Clinical trials that fulfilled eligibility criteria were included in this review. A meta-analysis was performed on depression and anxiety scores at post-test. Heterogeneity was assessed using the Chi2 and I2 indicators. For evaluating publication bias, we resorted to a funnel plot graph. Results: A total of 17 reports were selected, among which 4 articles studied the efficiency of acceptance and commitment therapy. Main demographic characteristics were homogenous throughout the included samples. The overall effect was -0.31 (95% CI: -0.47 to -0.15) for depression, and -0.15 (95%: -0.29 to -0.02), reaching statistical significance. Conclusions: Both psychological interventions proved to be efficient for decreasing depression and anxiety in fibromyalgia. For this reason, we believe psychotherapeutic protocols can be reliably implemented within multicomponent treatments, facilitating emotional adjustment in the context of physical disability and pain. Future research directions include the exploration of change processes and multiple moderators, enabling the development of tailored psychological treatments in fibromyalgia.

A Novel Scoring System Predicting Red Blood Cell Transfusion Requirements in Patients Undergoing Invasive Spine Surgery.

Background: Access to blood products is crucial for patient safety during the perioperative course. However, reduced donations and seasonally occurring blood shortages pose a significant challenge to the healthcare system, with surgeries being postponed. The German Blood Transfusion act requires that RBC packages become assigned to an individual patient, resulting in a significant reduction in the available blood products, further aggravating shortages. We aimed to develop a scoring system predicting transfusion probability in patients undergoing spine surgery to reduce assignment and, thus, increase the availability of blood products. Methods: The medical records of 252 patients who underwent spine surgery were evaluated and 18 potential predictors for RBC transfusion were tested to construct a logistic-regression-based predictive scoring system for blood transfusion in patients undergoing spine surgery. Results: The variables found to be the most important included the type of surgery, vertebral body replacement, number of stages, and pre-operative Hb concentration, indicating that surgical specification and the extent of the surgical procedure were more influential than the pre-existing patient condition and medication. Conclusions: Our model showed a good discrimination ability with an average AUC [min, max] of 0.87 [0.6, 0.97] and internal validation with a similar AUC of 0.84 [0.66, 0.97]. In summary, we developed a scoring system to forecast patients' perioperative transfusion needs when undergoing spine surgery using pre-operative predictors, potentially reducing the need for RBC allocation and, thus, resulting in an increased availability of this valuable resource.

Central venous catheter tip positioning using ultrasound in pediatric patients-A prospective observational study.

BACKGROUND: In children, central venous catheter (CVC) placement is usually performed under ultrasound guidance for optimal visualization of vessels and reduction of puncture-related complications. Nevertheless, in many cases, additional radiographic examinations are performed to check the position of the catheter tip. AIM: The primary objective of this observational feasibility study was to determine the number of ultrasound-guided central venous catheter tips that can be identified in a subsequent position check using ultrasonography. Furthermore, we investigated the optimal ultrasound window, time expenditure, and success rate concerning puncture attempts and side effects. In addition, we compared the calculated and real insertion depths and analyzed the position of the catheter tip on postoperative radiographs with the tracheal bifurcation as a traditional landmark. METHODS: Ninety children with congenital heart defects who required a central venous line for cardiac surgery were included in this single-center study. After the insertion of the catheter, the optimal position of its tip was controlled using one of four predefined ultrasound windows. A chest radiograph was obtained postoperatively in accordance with hospital standards to check the catheter tip position determined by ultrasonography. RESULTS: The children had a median (IQR) age of 11.5 (4.0, 58.8) months and a mean (SD) BMI of 15.3 (2.91) kg/m2 Ultrasound visualization of the catheter tip was successful in 86/90 (95.6%) children (95% confidence interval [CI]: 91.3%, 99.8%). Postoperative radiographic examination showed that the catheter tip was in the desired position in 94.4% (95% CI: 89.7%, 99.2%) of the cases. None of the children needed the catheter tip position being corrected based on chest radiography. CONCLUSION: Additional radiation exposure after the placement of central venous catheters can be avoided with the correct interpretation of standardized ultrasound windows, especially in vulnerable children with cardiac disease.

Pre-Interventional Risk Assessment in The Elderly (PIRATE): Development of a scoring system to predict 30-day mortality using data of the Peri-Interventional Outcome Study in the Elderly.

Risk assessment before interventions in elderly patients becomes more and more vital due to an increasing number of elderly patients requiring surgery. Existing risk scores are often not tailored to marginalized groups such as patients aged 80 years or older. We aimed to develop an easy-to-use and readily applicable risk assessment tool that implements pre-interventional predictors of 30-day mortality in elderly patients (≥80 years) undergoing interventions under anesthesia. Using Cox regression analysis, we compared different sets of predictors by taking into account their ease of availability and by evaluating predictive accuracy. Coefficient estimates were utilized to set up a scoring system that was internally validated. Model building and evaluation were based on data from the Peri-Interventional Outcome Study in the Elderly (POSE), which was conducted as a European multicenter, observational prospective cohort study. Our risk assessment tool, named PIRATE, contains three predictors assessable at admission (urgency, severity and living conditions). Discriminatory power, as measured by the concordance index, was 0.75. The estimated prediction error, as measured by the Brier score, was 0.036 (covariate-free reference model: 0.043). PIRATE is an easy-to-use risk assessment tool that helps stratifying elderly patients undergoing interventions with anesthesia at increased risk of mortality. PIRATE is readily available and applies to a wide variety of settings. In particular, it covers patients needing elective or emergency surgery and undergoing in-hospital or day-case surgery. Also, it applies to all types of interventions, from minor to major. It may serve as a basis for multidisciplinary and informed shared decision-making.

Prevalence of sleep-disordered breathing in patients with mitral regurgitation and the effect of mitral valve repair.

PURPOSE: The relationship between chronic heart failure and sleep-disordered breathing (SDB) has been frequently described. However, little is known about the association of mitral regurgitation (MR) and SDB or the impact of transcatheter mitral valve repair (TMVR) on SDB. Our aims were first to determine the prevalence of SDB in patients with MR, and second to determine the effect of TMVR on SDB. METHODS: Patients with MR being evaluated for TMVR at the University Hospital Bonn underwent polygraphy (PG) to determine the prevalence of SDB. After TMVR, a subset of patients was followed up with transthoracic echocardiography (TTE) and PG to evaluate the effect of TMVR on SDB. RESULTS: In 53 patients, mean age was 76.0 ± 8.5 years and 62% were male. Patients predominantly had more than moderate mitral regurgitation (94%). SDB was highly prevalent (68%) with predominantly central sleep apnoea (CSA, 67%). After TMVR in 15 patients, the apnoea/hypopnoea index (AHI) and central apnoea index (AI) were significantly reduced among patients with SDB (AHI - 8.0/h, p = 0.021; central AI - 6.9/h, p = 0.046). The left atrial volume index (LAVI) at baseline was significantly higher in patients with CSA than in patients with obstructive sleep apnoea (OSA) and was significantly reduced after TMVR (63.5 ml/m2 ± 27.2 vs. 38.3 ml/m2 ± 13.0; - 18.4 ml/m2, p = 0.027). CONCLUSION: SDB, especially CSA, is highly prevalent in patients with mitral regurgitation. In the follow-up cohort TMVR led to a significant reduction of the AHI, predominantly of central events. The findings of the study suggest that TMVR may be a suitable therapy not only for MR but also for the accompanying CSA. LAVI may be a useful indicator for CSA in patients with MR.

Genetic alterations of TP53 and OTX2 indicate increased risk of relapse in WNT medulloblastomas.

This study aimed to re-evaluate the prognostic impact of TP53 mutations and to identify specific chromosomal aberrations as possible prognostic markers in WNT-activated medulloblastoma (WNT-MB). In a cohort of 191 patients with WNT-MBs, mutations in CTNNB1, APC, and TP53 were analyzed by DNA sequencing. Chromosomal copy-number aberrations were assessed by molecular inversion probe technology (MIP), SNP6, or 850k methylation array hybridization. Prognostic impact was evaluated in 120 patients with follow-up data from the HIT2000 medulloblastoma trial or HIT registries. CTNNB1 mutations were present in 92.2%, and APC mutations in 6.8% of samples. One CTNNB1 wild-type tumor gained WNT activation due to homozygous FBXW7 deletion. Monosomy 6 was present in 78.6%, and more frequent in children than adults. 16.1% of tumor samples showed TP53 mutations, of those 60% with nuclear positivity for the p53 protein. Loss of heterozygosity at the TP53 locus (chromosome 17p13.1) was found in 40.7% (11/27) of TP53 mutant tumor samples and in 12.6% of TP53 wild-type cases (13/103). Patients with tumors harboring TP53 mutations showed significant worse progression-free survival (PFS; 5-year-PFS 68% versus 93%, p = 0.001), and were enriched for chromosomes 17p (p = 0.001), 10, and 13 losses. Gains of OTX2 (14q22.3) occurred in 38.9% of samples and were associated with poor PFS and OS (5-year-PFS 72% versus 93%, p = 0.017 resp. 5-year-OS 83% versus 97%, p = 0.006). Multivariable Cox regression analysis for PFS/OS identified both genetic alterations as independent prognostic markers. Our data suggest that patients with WNT-MB carrying TP53 mutations or OTX2 gains (58.1%) are at higher risk of relapse. Eligibility of these patients for therapy de-escalation trials needs to be debated.

Evaluation of a Paper-Based Checklist versus an Electronic Handover Tool Based on the Situation Background Assessment Recommendation (SBAR) Concept in Patients after Surgery for Congenital Heart Disease.

(1) Background: we compare a new SBAR based electronic handover tool versus a paper-based checklist for handover in a pediatric intensive care unit (PICU). (2) Methods: this is a randomized, observational study of 40 electronic vs. 40 paper checklist handovers after pediatric cardiac surgery, with a 48 items checklist for comparison of reporting frequencies and notification of disturbances and noise. PICU staff satisfaction was evaluated by a 12-item questionnaire. (3) Results: in 14 out of 40 cases, there were problems with data processing (incomplete or no data processing). Some item groups (e.g., hemodynamics) were consistently reported at higher frequencies than other groups. Items not specifically asked for did not get reported. Some items, automatically processed in the SBAR handover page, did not get reported. Many handovers suffered a noisy and distracting atmosphere. There was no difference in staff satisfaction between the two handover approaches. Nurses were highly unsatisfied with the general approach by which the handover was performed. (4) Conclusions: human error appears to be a main factor for unreliable data processing. Software is still too complicated, and multitasking is a stressful and error prone event. Handover is a complex task with many factors required for a successful completion.

Germline ancestry influences the evolutionary disease course in lung adenocarcinomas.

Precision medicine relies on targeting specific somatic alterations present in a patient's tumor. However, the extent to which germline ancestry may influence the somatic burden of disease has received little attention. We estimated the genetic ancestry of non-small-cell lung cancer (NSCLC) patients and performed an in-depth analysis of the influence of genetic ancestry on the evolutionary disease course. Compared with European Americans (EA), African Americans (AA) with lung adenocarcinoma (LUAD) were found to be significantly younger and smoke significantly less. However, LUADs from AAs exhibited a significantly higher somatic mutation burden, with a more pronounced tobacco carcinogen footprint and increased frequencies of alterations affecting cancer genes. Conversely, no significant differences were observed between lung squamous cell carcinomas (LUSC) from EAs and AAs. Our results suggest germline ancestry influences the somatic evolution of LUAD but not LUSC.