Implementing a Preoperative Anemia Optimization Protocol for Cardiovascular Surgery Patients: A Quality Improvement Project.

BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.

Preoperative investigation practices for elective surgical patients: clinical audit.

BACKGROUND: The findings of pre-operative investigations help to identify risk factors that may affect the course of surgery or post-operative recovery by contributing to informed consent conversations between the surgical team and the patient, as well as guiding surgical and anesthetic planning. Certainly, preoperative tests are valuable when they offer additional information beyond what can be gathered from a patient's history and physical examination alone. Preoperative testing practices differ significantly among hospitals, and even within the same hospital, clinicians may have varying approaches to requesting tests. This study aimed to investigate preoperative testing practices and compare them with the latest guidelines from the National Institute for Health and Care Excellence (NICE). METHODS: This three-month institutionally based study was carried out at the Debre Tabor Comprehensive Specialized Hospital from May 1 to July 30, 2023, including individuals aged 16 years and older who were not pregnant and had undergone elective surgery in the gynecological, orthopedic, and general units. Data on the sociodemographic characteristics, the existence of comorbidities, the invasiveness of surgery, and the tests taken into consideration by the guideline were gathered using a self-administered questionnaire. After rigorously analyzing and revising the results of preoperative investigation approaches, we compared them to the standard of recommendations. Moreover, the data was analyzed and graphically presented using Microsoft Excel 2013. RESULTS: During the data collection period, 247 elective patients underwent general, orthopedic, and gynecological operations. The majority of patients, 107 (43.32%), were between the ages of 16 and 40 and had an American Society of Anesthesiologists (ASA) class one (92.71%). 350 investigations were requested in total. Of these, 71 (20.28%) tests were ordered without a justified reason or in contravention of NICE recommendations. CONCLUSIONS: In our hospital's surgical clinical practice, unnecessary preoperative testing is still common, especially when it comes to organ function tests, electrocardiograms (ECGs), and complete blood counts (FBCs). When deciding whether preoperative studies are required, it is critical to consider aspects including a complete patient history, a physical examination, and the invasiveness of the surgery.

[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]. / Präoperative Evaluation erwachsener Patientinnen und Patienten vor elektiven, nicht herz-thoraxchirurgischen Eingriffen : Eine gemeinsame Empfehlung der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, der Deutschen Gesellschaft für Chirurgie und der Deutschen Gesellschaft für Innere Medizin.

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

Comparative validation of automated presurgical tractography based on constrained spherical deconvolution and diffusion tensor imaging with direct electrical stimulation.

OBJECTIVES: Accurate presurgical brain mapping enables preoperative risk assessment and intraoperative guidance. This cross-sectional study investigated whether constrained spherical deconvolution (CSD) methods were more accurate than diffusion tensor imaging (DTI)-based methods for presurgical white matter mapping using intraoperative direct electrical stimulation (DES) as the ground truth. METHODS: Five different tractography methods were compared (three DTI-based and two CSD-based) in 22 preoperative neurosurgical patients undergoing surgery with DES mapping. The corticospinal tract (CST, N = 20) and arcuate fasciculus (AF, N = 7) bundles were reconstructed, then minimum distances between tractograms and DES coordinates were compared between tractography methods. Receiver-operating characteristic (ROC) curves were used for both bundles. For the CST, binary agreement, linear modeling, and posthoc testing were used to compare tractography methods while correcting for relative lesion and bundle volumes. RESULTS: Distance measures between 154 positive (functional response, pDES) and negative (no response, nDES) coordinates, and 134 tractograms resulted in 860 data points. Higher agreement was found between pDES coordinates and CSD-based compared to DTI-based tractograms. ROC curves showed overall higher sensitivity at shorter distance cutoffs for CSD (8.5 mm) compared to DTI (14.5 mm). CSD-based CST tractograms showed significantly higher agreement with pDES, which was confirmed by linear modeling and posthoc tests (PFWE < .05). CONCLUSIONS: CSD-based CST tractograms were more accurate than DTI-based ones when validated using DES-based assessment of motor and sensory function. This demonstrates the potential benefits of structural mapping using CSD in clinical practice.

Coronary artery calcium assessment on non-gated chest CT to optimize pre-operative cardiac screening in liver transplantation.

BACKGROUND: Guidelines recommend standard pre-operative cardiac screening in all liver transplantation (LT) recipients, despite the relatively low prevalence of obstructive coronary artery disease. Most LT recipients often have non-gated computed tomography (CT) performed of the chest and abdomen. This study evaluated the ability of coronary artery calcification (CAC) assessment on consecutively available scans, to identify a selection of low-risk patients, in whom further cardiac imaging can be safely withheld. METHODS: LT recipients with prior non-gated CT chest-abdomen were included. CAC was visually scored on a semi-quantitative ordinal scale. Stress myocardial perfusion, coronary CT angiography (CCTA) and invasive coronary angiography (ICA) were used as golden standard. The sensitivity and specificity of CAC to exclude and predict obstructive CAD were assessed. In addition, peri- and postoperative mortality and cardiac events were analyzed. RESULTS: 149 LT recipients (ranged 31-71 years) were included. In 75% of patients, no CAC and mild CAC could rule out obstructive CAD on CCTA and ICA with 100% certainty. The threshold of mild CAC had a sensitivity of 100% for both CCTA and ICA and a specificity of 91% and 68%, respectively. None of the patients with no or mild calcifications experienced peri- and post-operative cardiac events or died of cardiac causes. CONCLUSION: Visual evaluation of CAC on prior non-gated CT can accurately and safely exclude obstructive CAD in LT recipients. Incorporation of these already available data can optimize cardiac screening, by safely withholding or correctly allocating dedicated cardiac imaging in LT recipients. Thereby, reducing patients' test burden and save health care expenses.

What is the association of preoperative biopsy with recurrence and survival in retroperitoneal sarcoma? A systematic review by the Australia and New Zealand Sarcoma Association clinical practice guidelines working party.

Preoperative biopsy for retroperitoneal sarcoma (RPS) enables appropriate multidisciplinary treatment planning. A systematic review of literature from 1990 to June 2022 was conducted using the population, intervention, comparison and outcome model to evaluate the local recurrence and overall survival of preoperative biopsy compared to those that had not. Of 3192 studies screened, five retrospective cohort studies were identified. Three reported on biopsy needle tract seeding, with only one study reporting biopsy site recurrence of 2 %. Two found no significant difference in local recurrence and one found higher 5-year local recurrence rates in those who had not been biopsied. Three studies reported overall survival, including one with propensity matching, did not show a difference in overall survival. In conclusion, preoperative core needle biopsy of RPS is not associated with increased local recurrence or adverse survival outcomes.

Visual supplementation is an effective tool in cataract surgery counselling by eye-care practitioners.

BACKGROUND: Informed consent constitutes an important aspect of eye care. However, patients often experience difficulties understanding and retaining information presented to them during consultations. This study investigates the efficacy of pictorial aids in supplementing preoperative counselling of patients undergoing cataract surgery. METHODS: Patients attending routine pre-cataract surgery counselling were randomized to receive either a standard verbal consultation (control) or a verbal consultation with a digitalized pictorial aid illustrating key surgical steps (intervention). Patients were assessed after the consultation on their knowledge, satisfaction, anxiety and preparedness using an anonymous questionnaire. RESULTS: Seventy-six patients were recruited and randomized into the control and intervention groups. The intervention group attained better Knowledge Scores (control: 5 [2-6] vs. intervention: 6 [6]), and more patients "strongly agreed" that they were more prepared (control: 78.9% vs. intervention: 97.4%, P=0.028). A higher proportion of patients in the control group either "disagreed" or "neither disagree nor agreed (neutral)" that they were less worried (control: 15.8% vs. intervention: 0.0%, Fisher's Exact Test P=0.025). Although the consultation duration was shorter in the intervention group (21±4mins vs. 27±6mins, P<0.001), the use of digital pictorial aids during consultation resulted in more effective counselling with increased patient knowledge, easier decision-making process and reduced patient anxiety. CONCLUSION: Pictorial aids add to the repository of tools available to eye-care practitioners and are low-cost, easy to implement, and can effectively augment existing preoperative counselling processes to ensure accurate and effective preoperative counselling of patients.

Evaluating the accuracy of ChatGPT-4 in predicting ASA scores: A prospective multicentric study ChatGPT-4 in ASA score prediction.

BACKGROUND: This study investigates the potential of ChatGPT-4, developed by OpenAI, in enhancing medical decision-making processes, particularly in preoperative assessments using the American Society of Anesthesiologists (ASA) scoring system. The ASA score, a critical tool in evaluating patients' health status and anesthesia risks before surgery, categorizes patients from I to VI based on their overall health and risk factors. Despite its widespread use, determining accurate ASA scores remains a subjective process that may benefit from AI-supported assessments. This research aims to evaluate ChatGPT-4's capability to predict ASA scores accurately compared to expert anesthesiologists' assessments. METHODS: In this prospective multicentric study, ethical board approval was obtained, and the study was registered with clinicaltrials.gov (NCT06321445). We included 2851 patients from anesthesiology outpatient clinics, spanning neonates to all age groups and genders, with ASA scores between I-IV. Exclusion criteria were set for ASA V and VI scores, emergency operations, and insufficient information for ASA score determination. Data on patients' demographics, health conditions, and ASA scores by anesthesiologists were collected and anonymized. ChatGPT-4 was then tasked with assigning ASA scores based on the standardized patient data. RESULTS: Our results indicate a high level of concordance between ChatGPT-4 predictions and anesthesiologists' evaluations, with Cohen's kappa analysis showing a kappa value of 0.858 (p = 0.000). While the model demonstrated over 90% accuracy in predicting ASA scores I to III, it showed a notable variance in ASA IV scores, suggesting a potential limitation in assessing patients with more complex health conditions. DISCUSSION: The findings suggest that ChatGPT-4 can significantly contribute to the medical field by supporting anesthesiologists in preoperative assessments. This study not only demonstrates ChatGPT-4's efficacy in medical data analysis and decision-making but also opens new avenues for AI applications in healthcare, particularly in enhancing patient safety and optimizing surgical outcomes. Further research is needed to refine AI models for complex case assessments and integrate them seamlessly into clinical workflows.

The deimplementation of laboratory testing in low-risk patients as recommended by the American society of anesthesiologists: An ACS-NSQIP longitudinal analysis.

BACKGROUND: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines. METHODS: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery. RESULTS: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes. CONCLUSIONS: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients.

Prehabilitation in gynecological oncology - are we ready to implement the program in polish oncological centers?

OBJECTIVES: Prehabilitation is a concept of holistic approach to the patient and includes preoperative efforts focused on optimalization of patient's general condition. The idea of prehabilitation started at the beginning of the 21st century. However, prehabilitation programs in gynecological cancer patients are not standardized and are heterogeneous. The aim of the study it to present the concept of prehabilitation and propose prehabilitation protocol to be introduced in Polish oncological centers. MATERIAL AND METHODS: A search in PubMed, Medline, EMBASE (Ovid) and PsycINFO databases was conducted using the following keywords: prehabilitation, gynecological, abdominal surgery, and cancer. The primary outcomes were complications, hospitalization stay, intensive care unit transfer rate, blood loss, wound healing, and reoperation rate. The search was performed in July 2022 and covered the period from 1st January 2000 till 30th June 2022. RESULTS: A total number of 1,118 articles have been identified. Out of all eligible papers only 42 fulfilled the research criteria and were included in the study. The analysis showed that there is no standardized prehabilitation protocol for gynecological cancer surgery, although most include three-modal approach - physical activity, nutrition, and psychological intervention. There is no standard model for physical capacity evaluation, however, 1,118 6 Minute Walk Test (6MWT) is the most common. Frailty evaluation is based on different measurements that prevent from direct comparison of obtained results between studies. CONCLUSIONS: We are not ready to implement the prehabilitation program in polish oncological centers. The main reason elvicz is: lack of accredited ovarian cancer centers, lack of well-established standardized prehabilitation programs for gynecological malignancies (ovarian cancer especially), and lack of proper information for patients about advantages of adequate preparation elvic expected surgery. Furter studies on different prehabilitation programs and information campaigns both for patients and gynecologist are required to make implementing prehabilitation possible in Poland.

[Polypharmacy and medication review in the context of prehabilitation]. / Polypharmazie und Medikamentencheck im Kontext der Prähabilitation.

Against the background of typical geriatric multimorbidity and with the particular vulnerability of geriatric patients, polypharmacy deserves special attention. In accordance with the guidelines, medication should not only be reviewed regularly, but also on an ad hoc basis and with each hospital stay-and also in the context of prehabilitation. Thus, not only substances that interfere with the currently planned intervention, anesthesia, or risk of bleeding should be considered, but any medication that increases common risks for geriatric patients. These include drugs that cause or increase a tendency to fall, induce delirium, or alter the comedication through potential drug-drug interactions. Measures to minimize the risk include the following: exact documentation of medications, structured and complete transfer of information, patient and family training about any side effects that may occur, a recall system for possible laboratory checks, and compliance with the instructions for taking the medication.

Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study.

BACKGROUND: Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. METHODS: Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. RESULTS: A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). CONCLUSIONS: Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium.

Diagnostic Performance of the Caprini Risk Assessment Model Combined With D-Dimer for Preoperative Deep Vein Thrombosis in Patients With Thoracolumbar Fractures Caused by High-Energy Injuries.

OBJECTIVE: To assess the validity of the Caprini risk assessment model (RAM) in risk stratification for deep vein thrombosis (DVT) and to investigate the diagnostic value of Caprini score combined with D-dimer in predicting DVT. METHODS: This study involved 429 patients with thoracolumbar fractures caused by high-energy injuries between October 2016 and November 2019. All patients were treated surgically and had a mean age of 45.3 ± 11.4 years. Patients were risk-stratified using the 2013 Caprini RAM. Mechanical and chemical prophylaxis were used for DVT. Duplex ultrasound of both lower extremities was performed before surgery. RESULTS: Of the 429 patients, 62 (14.45%) developed DVT. The incidence of preoperative DVT was correlated with Caprini score according to risk stratification(χ2 = 117.4, P < 0.001). Based on the original Caprini RAM, all the patients scored in the highest risk category (score ≥5). Further substratification showed that the majority (277 of 429, 64.57%) of the patients were in the Caprini score range 7-8 and the risk of preoperative DVT was significantly higher among patients with Caprini score >10. The area under the receiver operating characteristic curve of Caprini score and D-dimer was 0.816 and 0.769 when Caprini score >8 or D-dimer >1.81mg/L was considered the criterion of predicting the risk of DVT. When combining the 2 variables, the area under the ROC curve can increase to 0.846. CONCLUSIONS: The Caprini RAM is an effective and reliable DVT risk stratification tool in patients with thoracolumbar fractures caused by high-energy injuries. Caprini score >8 or D-dimer >1.81 mg/L may predict the occurrence of preoperative DVT and the Caprini score combined with D-dimer exhibit better diagnostic performance.

Rethinking the routine: Preoperative laboratory testing among American Society of Anesthesiologists class 1 and 2 patients before low-risk ambulatory surgery in the 2017 National Surgical Quality Improvement Program cohort.

BACKGROUND: Routine preoperative laboratory testing is not recommended for American Society of Anesthesiologists classification 1 or 2 patients before low-risk ambulatory surgery. METHODS: The 2017 National Surgical Quality Improvement Program data set was retrospectively queried for American Society of Anesthesiologists class 1 and 2 patients who underwent low-risk, elective outpatient anorectal, breast, endocrine, gynecologic, hernia, otolaryngology, oral-maxillofacial, orthopedic, plastic/reconstructive, urologic, and vascular operations. Preoperative laboratory testing was defined as any chemistry, hematology, coagulation, or liver function studies obtained ≤30 days preoperatively. Demographics, comorbidities, and outcomes were compared between those with and without testing. The numbers needed to test to prevent serious morbidity or any complication were calculated. Laboratory testing costs were estimated using Centers for Medicare and Medicaid Services data. RESULTS: Of 111,589 patients studied, 57,590 (51.6%) received preoperative laboratory testing; 26,709 (46.4%) had at least 1 abnormal result. Factors associated with receiving preoperative laboratory testing included increasing age, female sex, non-White race/ethnicity, American Society of Anesthesiologists class 2, diabetes, dyspnea, hypertension, obesity, and steroid use. Mortality did not differ between patients with and without testing. The complication rate was 2.5% among tested patients and 1.7% among patients without tests (P < .01). The numbers needed to test was 599 for serious morbidity and 133 for any complication. An estimated $373 million annually is spent on preoperative laboratory testing in this population. CONCLUSION: Despite American Society of Anesthesiologists guidelines, a majority of American Society of Anesthesiologists class 1 and 2 patients undergo preoperative laboratory testing before elective low-risk outpatient surgery. The differences in the rates of complications between patients with and without testing is low. Preoperative testing should be used more judiciously in this population, which may lead to cost savings.

Diagnosis of presence and extent of deep infiltrating endometriosis by preoperative MRI-improvement of staging accuracy by expert training.

INTRODUCTION: This study evaluates the clinical utility of magnetic resonance imaging (MRI) for the determination of presence and extent of DIE with special emphasis on effects of MRI reporting training MATERIAL AND METHODS: Data from 80 patients with clinically suspected DIE presented at our certified endometriosis center between 2015 and 2018 were analyzed. For all patients an ENZIAN score (describing DIE related to individual anatomical localizations) was obtained based on the preoperative MRI findings. The intraoperatively determined ENZIAN score served as the reference for assessment of diagnostic performance of the MRI. RESULTS: Overall, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of DIE by MRI were 76.9%, 53.3%, 87.7% and 34.8%, respectively. Analysis by compartment revealed a sensitivity, specificity, PPV and NPV of 59.5%, 88.2%, 86.2% and 63.9%, respectively, for compartment A, with similar values for compartment B, and 50.0%, 88.9%, 64.7% and 81.4%, respectively, for the less often affected compartment C. Expert training (n = 32 before, n = 48 after) led to a considerable increase in sensitivities for the overall detection of DIE (84.6% vs. 65.4%, p = 0.071) and for the detection of DIE in compartment A (71.4% vs. 35.7%, p = 0.026), compartment B (66.7% vs. 37.5%, p = 0.057) and compartment C (75.0% vs. 20.0%, p = 0.010), without significant loss in specificity (all p > 0.50). DISCUSSION: After expert training, MRI has a good sensitivity with fair specificity regarding preoperative assessment of presence, location and extent of DIE.

Perioperative management of severe brain injured patients.

Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery; and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.

COVID-19 Preprocedure Testing Considerations.

The COVID-19 pandemic has presented significant patient and provider safety concerns, notably for clinicians involved in aerosol-generating procedures. Healthcare systems established new and innovative ways to function safely and maintain operations, including mandatory preoperative testing, changes to patient scheduling, infection control practices, staffing, surgical prioritization, environmental cleaning, and operating room processing. This article provides practice and policy considerations for preprocedure COVID-19 testing, taking into consideration the available evidence and variability in community prevalence, rate of vaccinations, and new COVID-19 variants.

Informed Consent for Intraoperative Neural Monitoring in Thyroid and Parathyroid Surgery - Consensus Statement of the International Neural Monitoring Study Group.

In the past decade, the use of intraoperative neural monitoring (IONM) in thyroid and parathyroid surgery has been widely accepted by surgeons as a useful technology for improving laryngeal nerve identification and voice outcomes, facilitating neurophysiological research, educating and training surgeons, and reducing surgical complications and malpractice litigation. Informing patients about IONM is not only good practice and helpful in promoting the efficient use of IONM resources but is indispensable for effective shared decision making between the patient and surgeon. The International Neural Monitoring Study Group (INMSG) feels complete discussion of IONM in the preoperative planning and patient consent process is important in all patients undergoing thyroid and parathyroid surgery. The purpose of this publication is to evaluate the impact of IONM on the informed consent process before thyroid and parathyroid surgery and to review the current INMSG consensus on evidence-based consent. The objective of this consensus statement, which outlines general and specific considerations as well as recommended criteria for informed consent for the use of IONM, is to assist surgeons and patients in the processes of informed consent and shared decision making before thyroid and parathyroid surgery.

Commentary in response to BMC Urology publication entitled "Infection-related hospitalization following ureteroscopic stone treatment: results from a surgical collaborative".

This Commentary is in response to the BMC Urology publication entitled "Infection-related hospitalization following ureteroscopic stone treatment: Results from a surgical collaborative". This study utilized a registry with prospectively recorded standardized data elements named Reducing Operative Complications from Kidney Stones, part of the Michigan Urological Surgery Improvement Collaborative, to identify risk factors of infection-related hospitalization after ureteroscopy for stone treatment. The study included 1817 primary URS procedures for urinary stones in 11 practices in Michigan. They found 43 patients (2.4%) were hospitalized with an infection-related complication and 3 patients died during their hospitalization (0.2% mortality rate). Just over 20% of patients did not have a pre-operative urinalysis or urine culture, representing a deviation from guideline recommendations. Also, in the hospitalized group, none of the 12 patients (27.9%) who had a positive pre-operative urinalysis or urine culture received pre-operative treatment. A multivariable analysis identified higher Charleston Comorbidity Index, history of recurrent urinary tract infection, increasing stone size, intraoperative complications, and fragments left in-situ as independent risk factors for hospitalization from an infection after ureteroscopy. This commentary discusses caveats to the data as well as short-comings of the study. It also reviews more broadly infection after ureteroscopy, includes findings from similar studies, and highlights guideline recommendations to reduce infection risk.