Isotonic balanced fluid versus 0.9% saline in patients with moderate to severe traumatic brain injury: A double-blinded randomised controlled trial.

BACKGROUND AND IMPORTANCE: Traumatic brain injury (TBI) is a global health concern with significant economic impact. Optimal fluid therapy aims to restore intravascular volume, maintain cerebral perfusion pressure and blood flow, thus preventing secondary brain injury. While 0.9% saline (NS) is commonly used, concerns about acid-base and electrolyte imbalance and development of acute kidney injury (AKI) lead to consideration of balanced fluids as an alternative. OBJECTIVES: This study aimed to compare the outcomes of patients with moderate to severe TBI treated with Sterofundin (SF) versus NS. DESIGN, SETTINGS AND PARTICIPANTS: A double-blinded randomised controlled trial of patients aged 18 to 65 years with TBI was conducted at the University Malaya Medical Centre from February 2017 to November 2019. INTERVENTION OR EXPOSURE: Patients were randomly assigned to receive either NS or SF. The study fluids were administered for 72 h as continuous infusions or boluses. Participants, investigators, and staff were blinded to the fluid type. OUTCOMES MEASURE AND ANALYSIS: The primary outcome was in-hospital mortality. Relative risk (RR) with 95% confidence interval (CI) was calculated. MAIN RESULTS: A total of 70 patients were included in the analysis, with 38 in the NS group and 32 in the SF group. The in-hospital mortality rate were 3 (7.9%) in the NS group vs. 4 (12.5%) in the SF group, RR = 1.29 (95% CI, 0.64 to 2.59; p = 0.695). No patients developed AKI and required renal replacement therapy. ICP on day 3 was significantly higher in the SF group (18.60 ± 9.26) compared to 12.77 ± 3.63 in the NS group, (95% CI, -11.46 to 0.20; p = 0.037). There were no significant differences in 3-day biochemical parameters and cerebral perfusion pressure, ventilator-free days, length of ICU stay, or Glasgow Outcome Scale-Extended (GOS-E) score at 6 months. CONCLUSIONS: In patients with moderate to severe TBI, the use of SF was not associated with reduced in-hospital mortality, development of AKI, or improved 6-month GOS-E when compared to NS.

Analysis of duration of different stages of surgery in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) patients: comparison between severe versus non-severe AIS.

PURPOSE: Prolonged surgical duration in severe adolescent idiopathic scoliosis (AIS) patients is associated with increased blood loss and perioperative complications. The aim of this study was to compare the duration of each stage of posterior spinal fusion (PSF) in severe AIS (Cobb angle ≥ 90°) with non-severe AIS patients. This analysis will identify the most time-consuming stage of PSF and help surgeons formulate strategies to shorten operative time. METHODS: Retrospective study whereby 90 AIS patients (Lenke type 2, 3, 4, and 6) who underwent PSF from 2019 to 2023 were recruited. Twenty-five severe AIS patients were categorized in Gp1 and 65 non-severe AIS patients in Gp2. Propensity score matching (PSM) with one-to-one with nearest neighbor matching (match tolerance 0.05) was performed. Outcomes measured via operation duration of each stage of surgery, blood loss, number of screws, fusion levels and screw density. RESULTS: Twenty-five patients from each group were matched. Total operative time was significantly higher in Gp1 (168.2 ± 30.8 vs. 133.3 ± 24.0 min, p < 0.001). The lengthiest stage was screw insertion which took 58.5 ± 13.4 min in Gp1 and 44.7 ± 13.7 min in Gp2 (p = 0.001). Screw insertion contributed 39.5% of the overall increased surgical duration in Gp1. Intraoperative blood loss (1022.2 ± 412.5 vs. 714.2 ± 206.7 mL, p = 0.002), number of screws (17.1 ± 1.5 vs. 15.5 ± 1.1, p < 0.001) and fusion level (13.1 ± 0.9 vs. 12.5 ± 1.0, p = 0.026) were significantly higher in Gp1. CONCLUSION: Screw insertion was the most time-consuming stage of PSF and was significantly longer in severe AIS. Adjunct technologies such as CT-guided navigation and robotic-assisted navigation should be considered to reduce screw insertion time in severe AIS.

Optimising operating theatre (OT) efficiency while maintaining the standardised patient care in adolescent idiopathic scoliosis (AIS) surgery with the dedicated spine team approach: a specialised spine unit experience.

PURPOSE: To report the efficiency of OT utilisation and perioperative outcomes with a dedicated spine team approach in AIS patients who underwent posterior spinal fusion (PSF) surgeries in a consecutive case operation list. METHODS: Three AIS patients operated in a day (8:00 AM-8:00 PM) by a dedicated spine team were recruited between 2021 and 2022. The dedicated team comprised of three senior spine consultants who operated using a dual attending surgeon strategy, an anaesthetic consultant, dedicated surgical scrub nurses, anaesthesiology nurses, radiographers, and neuromonitoring technicians. Patients were categorised according to the sequence of operation list of the day (Case 1, Case 2, and Case 3). OT efficiency was represented by OT time in five stages (preoperative time, operative time, postoperative time, total OT time, and turnover time). OT time and perioperative outcomes were compared. RESULTS: 102 cases were analysed. On average, Case 1 began at 8:38 AM whereas Case 3 ended by 5:54 PM. OT efficiency was consistent throughout the day of operation with comparable OT time in all five stages between groups (p > 0.05). The mean turnover time was 15.1 ± 13.5 min and the mean operative time was 123.0 ± 28.1 min. Intraoperative arterial blood gas (ABG) parameters were maintained in an optimal range. The complication rate was 2.0% (N = 2/102). CONCLUSION: Consistent OT efficiency was demonstrated with a dedicated spine team approach. Despite performing three AIS cases in a consecutive case operation list, patients' safety was not compromised as perioperative outcomes between groups were comparable.

Severe Lenke 1 and 2 adolescent idiopathic scoliosis had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost compared to non-severe scoliosis.

PURPOSE: To compare the perioperative outcome and operative cost of posterior spinal fusion (PSF) surgery between severe and non-severe Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) patients. METHODS: A total of 509 AIS patients who underwent single-staged PSF between 2013 and 2020 were reviewed. Fifty-four severe scoliosis patients (Cobb angle ≥ 90°) were categorized into Gp1, and 455 non-severe scoliosis (Cobb angle < 90°) patients into Gp2. Propensity score matching (PSM) analysis using one-to-one nearest neighbor matching and match tolerance of 0.001 were performed. Outcome measures were operative time, intraoperative blood loss (IBL), allogeneic transfusion rate, perioperative complication, length of stay, fusion level, number of screws used, postoperative Cobb angle, correction rate (CR), side bending correction index (SBCI) and operative cost. RESULTS: From the PSM analysis, 35 patients from each group were matched. The operative time was 155.9 ± 41.4 and 130.0 ± 30.3 min for Gp1 and Gp2, respectively (p = 0.004). The IBL was 1349.2 ± 1019.0 and 781.9 ± 325.1 mLs for Gp1 and Gp2, respectively (p = 0.003). Fusion level (12.5 ± 0.8 vs. 11.2 ± 1.3, p < 0.001) and number of screws used (16.4 ± 1.6 vs. 14.6 ± 1.4, p < 0.001) were higher in Gp1. Four perioperative complications were observed in Gp1 compared to none in Gp2 (p < 0.039). Gp1 had larger postoperative Cobb angle (p < 0.001), lower CR (p = 0.005) and higher SBCI (p < 0.001). The operative cost was higher in Gp1 (p < 0.001). CONCLUSIONS: Severe Lenke 1 and 2 AIS patients had poorer perioperative outcome, higher complication rate, longer fusion and higher operative cost than non-severe AIS.

Perioperative outcome and complications following single-staged Posterior Spinal Fusion (PSF) using pedicle screw instrumentation in Adolescent Idiopathic Scoliosis (AIS): a review of 1057 cases from a single centre.

BACKGROUND: There has been a growing interest in using all pedicle screw construct in posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) surgery in recent years. However, studies focusing on perioperative outcome and complications utilizing only pedicle screw system in AIS population are lacking. This study aims to evaluate perioperative outcomes and to determine the prevalence of major and minor complications following single-staged PSF for AIS. METHODS: In this retrospective study of prospectively collected data, 1057 AIS patients operated between 2012 and 2019 were included. Main outcome measures were operative time, intraoperative blood loss, allogeneic blood transfusion rate, length of hospital stay after surgery, complication rate, and mean drop of haemoglobin (Hb) level. We documented the number of fusion levels, screw density, and postoperative radiographic parameters. RESULTS: There were 917 females and 140 males. Majority were Lenke 1 curve type (46.9%). Mean age was 15.6 ± 3.7 years, with mean BMI of 18.6 ± 3.2 kg/m2. Mean operative time was 146.8 ± 49.4 min. Average intraoperative blood loss was 952.9 ± 530.4 ml with allogeneic blood transfusion rate of 5%. Mean screw density was 1.27 ± 0.21 screws per fusion level. Average hospital stay after surgery was 3.5 ± 0.9 days. Twenty-four complications were documented: twelve superficial infections (1.14%), five transient neurological deficits (0.47%), two deep infections (0.19%), two superior mesenteric artery syndrome, and one case each (0.09%) for massive intraoperative blood loss, intraoperative seizure, and lung atelectasis. CONCLUSION: AIS patients treated with single-staged PSF using pedicle screw construct had a 0.95% rate of major complications and 1.32% rate of minor complications. Rate of neurologic complication was 0.47% while non-neurologic postoperative complications was 1.80% with infection being the leading complication at 1.32%.

The hemodynamic and pain impact of peripheral nerve block versus spinal anesthesia in diabetic patients undergoing diabetic foot surgery.

PURPOSE: Comparison of hemodynamic profiles and pain scores in diabetic patients undergoing diabetic foot surgery receiving peripheral nerve block (PNB) or spinal anesthesia [subarachnoid block (SAB)]. METHODS: This was a prospective, randomised controlled trial. We recruited diabetic patients aged > 18 years, American Society of Anesthesiologists class II-III, who were scheduled for unilateral diabetic foot surgery below the knee. All patients were assessed for autonomic dysfunction using the Survey of Autonomic Symptoms score. Participants were randomly assigned to receive either PNB or SAB for the surgery. Hemodynamic data, including usage of vasopressors, were recorded at 5-min intervals for up to 1 h after the induction of anesthesia. Pain scores were recorded postoperatively, and follow-up was done via telephone 6 months later. RESULTS: Compared to the PNB group, the SAB group had a larger number of patients with significant hypotension (14 vs. 1; p = 0.001) and more patients who required vasopressor boluses (6 vs. 0 patients). Compared to SAB group, the patients in the PNB group had a longer postoperative pain-free duration (9 vs. 4.54 h; p = 0.002) and lower pain scores 1 day after surgery (3.63 vs. 4.69; p = 0.01). CONCLUSION: Peripheral nerve block should be considered, whenever possible, as the first option of anesthesia for lower limb surgery in diabetic patients as it provides hemodynamic stability and superior postoperative pain control compared to SAB. TRIAL REGISTRATION: Clinical trial registry: ClinicalTrials.gov. ID NCT02727348.

Islamic Considerations on the Application of Patient's Autonomy in End-of-Life Decision.

In end-of-life situation, the need for patient's preference comes into the picture with the intention of guiding physicians in the direction of patient care. Preference in medical directive is made by a person with full mental capacity outlining what actions should be taken for his health should he loses his competency. This is based on the reality of universal paradigm in medical practice that emphasises patient's autonomy. A specific directive is produced according to a patient's wish that might include some ethically and religiously controversial directives such as mercy killing, physician-assisted suicide, forgoing life-supporting treatments and do-not-resuscitate. In the future, patient autonomy is expected to become prevalent. The extent of patient autonomy has not been widely discussed among Muslim scholars. In Islam, there are certain considerations that must be adhered to.

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Importance: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. Objective: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. Design, Setting, and Participants: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. Interventions: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. Main Outcomes and Measures: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. Results: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. Conclusions and Relevance: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. Trial Registration: clinicaltrials.gov Identifier: NCT01374022.

Protocol and statistical analysis plan for the mega randomised registry trial comparing conservative vs. liberal oxygenation targets in adults in the intensive care unit with suspected hypoxic ischaemic encephalopathy following a cardiac arrest (Mega-ROX HIE).

Background: The effect of conservative vs. liberal oxygen therapy on 90-day in-hospital mortality in adults with hypoxic ischaemic encephalopathy (HIE) following a cardiac arrest who are receiving invasive mechanical ventilation in the intensive care unit (ICU) is uncertain. Objective: To summarise the protocol and statistical analysis plan for the Mega-ROX HIE trial. Design setting and participants: Mega-ROX HIE is an international randomised clinical trial that will be conducted within an overarching 40,000-participant registry-embedded clinical trial comparing conservative and liberal ICU oxygen therapy regimens. We expect to enrol approximately 4000 participants with suspected HIE following a cardiac arrest who are receiving invasive mechanical ventilation in the ICU. Main outcome measures: The primary outcome is in-hospital all-cause mortality up to 90 days from the date of randomisation. Secondary outcomes include duration of survival, duration of mechanical ventilation, ICU length of stay, hospital length of stay, and the proportion of participants discharged home. Results and conclusions: Mega-ROX HIE will compare the effect of conservative vs. liberal oxygen therapy regimens on day-90 in-hospital mortality in adults in the ICU with suspected HIE following a cardiac arrest. The protocol and planned analyses are reported here to mitigate analysis bias. Trial registration: Australian and New Zealand Clinical Trials Registry (ACTRN 12620000391976).

A Comparison Between the Perioperative Outcomes of Female Adolescent Idiopathic Scoliosis (AIS) Versus Adult Idiopathic Scoliosis (AdIS) Following Posterior Spinal Fusion: A Propensity Score Matching Analysis Involving 425 Patients.

STUDY DESIGN: Retrospective propensity score matching (PSM) study. OBJECTIVE: To investigate the perioperative outcomes comparing adolescent idiopathic scoliosis (AIS) and adult idiopathic scoliosis (AdIS) patients following posterior spinal fusion (PSF). METHODS: 425 female AIS and AdIS patients who were operated (between January 2015 to March 2020) using a dual attending surgeon strategy were stratified into G1 (AIS aged 10-16 years old) and G2 (AdIS > 20 years old). PSM analysis with one-to-one, nearest neighbor matching technique with match tolerance of 0.001 was used to matched 357 AIS patients to 68 AdIS patients. Operation duration, intraoperative blood loss (IBL), blood loss percentage, hemoglobin drift, blood salvaged, postoperative wound length, allogenic blood transfusion requirement, postoperative hospital stay, postoperative Cobb, correction rate and postoperative complications were documented and reported. RESULTS: Following PSM, G1 and G2 each had 50 patients with comparable and balanced covariates. As anticipated, G2 patients were heavier, taller and had higher body mass index compared to G1 patients (P < 0.05). We could not find any significant differences in the perioperative outcome comparing this 2 groups. AIS and AdIS patients had similar operation duration (125.9 ± 27.2 min vs 127.3 ± 37.8 min), IBL (749.8 ± 315.7 ml vs 723.8 ± 342.1 ml) and length of hospital stay (3.3 ± 0.4 days vs 3.5 ± 0.8 days) (P > 0.05). Hemoglobin drift and amount of blood salvaged were comparable (P > 0.05). G2 had stiffer curves. There was a trend toward a lower correction rate in G2 in the immediate postoperative period, however it did not reach statistical significance (61.8 ± 11.2% vs. 66.3 ± 11.6%, P = 0.051). No patients required blood transfusion and none had any postoperative complications. CONCLUSION: Adolescent and adult female scoliosis patients had comparable perioperative outcome following PSF surgery that was carried out using a dual attending surgeon strategy.

Factors Affecting Operation Duration in Posterior Spinal Fusion (PSF) Using Dual Attending Surgeon Strategy Among Lenke 1 and 2 Adolescent Idiopathic Scoliosis (AIS) Patients.

STUDY DESIGN: This was a retrospective study. SUMMARY OF BACKGROUND DATA: Prolonged operation duration in adolescent idiopathic scoliosis (AIS) surgery was associated with increased perioperative complications. However, the factors affecting operation duration in AIS surgery were unknown. OBJECTIVE: The aim of the study was to investigate the factors affecting operation duration in posterior spinal fusion (PSF) surgery using a dual attending surgeon strategy among Lenke 1 and 2 AIS patients. METHODS: In all, 260 AIS patients with Lenke 1 and 2 curves who underwent PSF were retrospectively reviewed. Preoperative and intraoperative factors affecting operation duration such as age, sex, height, weight, body mass index, Risser grade, Lenke subtypes, number of fusion level, number of screws, screw density, wound length, upper and lowest instrumented vertebrae level, preoperative Cobb angle, and flexibility of the major curve were assessed using univariate and multivariate linear regression analyses. Independent factors were determined when P-value <0.05. RESULTS: The mean operation duration was 122.2±28.6 minutes. Significant independent factors affecting operation duration in PSF among Lenke 1 and 2 AIS patients were Lenke 2 subtypes (ß=8.86, P=0.008), number of screws (ß=7.01, P<0.001), wound length (ß=1.14, P=0.009), and flexibility of the major curve (ß=-0.25, P=0.005). The overall model fit was R2=0.525. Operation duration can be predicted using the formula: (8.86×Lenke subtypes)+(7.01×number of screws)+(1.14×wound length)-(0.25×flexibility)-0.54, where Lenke 2=1 and Lenke 1=0. CONCLUSION: The factors affecting operation duration in PSF among Lenke 1 and 2 AIS patients were Lenke 2 curves, number of screws, wound length, and curve flexibility. The knowledge of these factors enables the spinal deformity surgeons to plan and estimate the operation duration before AIS surgery.

Prone ventilation in intubated COVID-19 patients: a systematic review and meta-analysis.

BACKGROUND: The efficacy and safety profiles of prone ventilation among intubated Coronavirus Disease 2019 (COVID-19) patients remain unclear. The primary objective was to examine the effect of prone ventilation on the ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) in intubated COVID-19 patients. METHODS: Databases of MEDLINE, EMBASE and CENTRAL were systematically searched from inception until March 2021. Case reports and case series were excluded. RESULTS: Eleven studies (n = 606 patients) were eligible. Prone ventilation significantly improved PaO2/FiO2 ratio (studies: 8, n = 579, mean difference 46.75, 95% CI 33.35‒60.15, p < 0.00001; evidence: very low) and peripheral oxygen saturation (SpO2) (studies: 3, n = 432, mean difference 1.67, 95% CI 1.08‒2.26, p < 0.00001; evidence: ow), but not the arterial partial pressure of carbon dioxide (PaCO2) (studies: 5, n = 396, mean difference 2.45, 95% CI 2.39‒7.30, p = 0.32; evidence: very low), mortality rate (studies: 1, n = 215, Odds Ratio 0.66, 95% CI 0.32‒1.33, p = 0.24; evidence: very low), or number of patients discharged alive (studies: 1, n = 43, Odds Ratio 1.49, 95% CI 0.72‒3.08, p = 0.28; evidence: very low). CONCLUSION: Prone ventilation improved PaO2/FiO2 ratio and SpO2 in intubated COVID-19 patients. Given the substantial heterogeneity and low level of evidence, more randomized- controlled trials are warranted to improve the certainty of evidence, and to examine the adverse events of prone ventilation.

Tranexamic Acid in Pediatric Scoliosis Surgery: A Prospective Randomized Trial Comparing High-dose and Low-dose Tranexamic Acid in Adolescent Idiopathic Scoliosis Undergoing Posterior Spinal Fusion Surgery.

STUDY DESIGN: Prospective randomized double-blinded trial. OBJECTIVE: The objective of this study is to determine the efficacy of high-dose versus low-dose tranexamic acid (TXA) in adolescent idiopathic scoliosis (AIS) corrective surgery. SUMMARY OF BACKGROUND DATA: Corrective surgery for AIS is associated with significant blood loss. Evidence on the optimum TXA dose to reduce bleeding in pediatric population is scarce. METHODS: A total of 166 AIS patients aged between 10 and 21 years, of American Society of Anesthesiologists (ASA) physical status I and II, preoperative hemoglobin >10 g/dL, platelet count >150,000 cells/L and Cobb angle of >45° scheduled for elective single-stage posterior spinal fusion (PSF) surgery by two attending surgeons were included between March 2017 and November 2018. Patients were randomized into Group A (High Dose, 30 mg/kg TXA loading dose followed by 10 mg/kg/h infusion) and Group B (Low Dose, 10 mg/kg TXA loading dose followed by 1 mg/kg/h infusion). The primary outcome was total surgical blood loss between both groups. Secondary outcomes were transfusion requirement, perioperative changes in hemoglobin and coagulation profiles, adverse events, and factors that influence total blood loss. RESULTS: The mean total surgical blood loss between the two groups was not significant (Group A: 928.8 ±â€Š406.1 mL [range: 348-1857 mL]; Group B: 918.1 ±â€Š406.2 mL [range: 271-2000 mL], P = 0.865). The median duration of surgery was 120 minutes. One patient in each group received allogenic blood transfusion during the perioperative period. There were no significant changes in hemoglobin and coagulation profile at pre-operation, post-operation 0 hour and 48 hours. Sex, number of vertebral levels fused, and duration of surgery were independently associated with total surgical blood loss. No adverse events were observed perioperatively. CONCLUSION: Low-dose TXA was as efficacious as high-dose TXA in reducing blood loss and allogenic blood transfusion for AIS patients undergoing PSF surgery.Level of Evidence: 1.

Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis.

STUDY OBJECTIVE: To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19). DESIGN: Systematic review and meta-analysis of non-randomized trials. PATIENTS: Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021. INTERVENTIONS: COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated. MEASUREMENTS: Primary outcomes were oxygenation parameters (PaO2/FiO2 ratio, PaCO2, SpO2). Secondary outcomes included the rate of intubation and mortality rate. RESULTS: Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO2/FiO2 ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO2 (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups. CONCLUSION: Our meta-analysis demonstrated that prone position improved PaO2/FiO2 ratio with better SpO2 than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence. PROSPERO Registration: CRD42021234050.

Dual attending surgeon strategy learning curve in single-staged posterior spinal fusion (PSF) surgery for 415 idiopathic scoliosis (IS) cases.

BACKGROUND CONTEXT: The implementation of a dual attending surgeon strategy had improved perioperative outcomes of idiopathic scoliosis (IS) patients. Nevertheless, the learning curve of a dual attending surgeon practice in single-staged posterior spinal fusion (PSF) surgery has not been established. OBJECTIVE: To evaluate the surgical learning curve of a dual attending surgeon strategy in IS patients. STUDY DESIGN: Retrospective study. PATIENT SAMPLE: 415 IS patients (Cobb angle <90°) who underwent PSF using a dual attending surgeon strategy OUTCOME MEASURES: Primary outcomes included operative time, total blood loss, allogenic blood transfusion requirement, length of hospital stay and perioperative complication rate. METHODS: Regression analysis using Locally Weighted Scatterplot Smoothing (LOWESS) method was applied to create the best-fit-curve between case number versus operative time and total blood loss in identifying cut-off points for the learning curve. RESULTS: The mean Cobb angle was 60.8±10.8°. Mean operative time was 134.4±32.1 minutes and mean total blood loss was 886.0±450.6 mL. The mean length of hospital stay was 3.0±1.6 days. The learning curves of a dual attending surgeon strategy in this study were established at the 115th case (operative time) and 196th case (total blood loss) respectively (p<.001). In comparison of cases before and after the cut-off points, mean operative time reduced significantly from 147.2±36.5 minutes to 129.5±28.9 minutes and mean total blood loss reduced significantly from 1015.1±506.6 mL to 770.4±357.3 mL (p<.001). No allogenic blood transfusion was required and there were 7 perioperative complications (n=7/415, 1.7%) recorded. CONCLUSION: The learning curve of a dual surgeon strategy in single-staged PSF surgery based on operative time and total blood loss were established at 115th case and 196th case respectively (p<.001).

Neuropathic Pain after Adolescent Idiopathic Scoliosis Correction Surgery.

STUDY DESIGN: Prospective study. PURPOSE: To investigate the prevalence and the associated risk factors of chronic neuropathic pain symptoms using painDETECT questionnaire in adolescent idiopathic scoliosis (AIS) patients who underwent posterior spinal fusion (PSF) surgery. OVERVIEW OF LITERATURE: Post-lumbar surgery syndrome is a disease entity that describes neuropathic pain following spinal surgery. However, few studies have investigated the prevalence and risk factors for neuropathic pain in pediatric population undergoing corrective spinal surgery. METHODS: Forty AIS patients were recruited. Demographic, preoperative, and postoperative data were recorded. The magnitude and characteristics of postoperative pain were assessed using the painDETECT questionnaire through telephone enquiries at intervals of 2, 6, 12, and 24 weeks. Statistical analyses were followed by Pearson correlation test to determine the relationship between pain scores at 6, 12, and 24 weeks with the risk factors. RESULTS: Based on the painDETECT questionnaire, 90% of the patients had nociceptive pain, and 10% had a possible neuropathic pain component at 2 weeks postoperatively as per a mean painDETECT score of 7.1±4.5. Assessments at 6, 12, and 24 weeks showed that no patients had neuropathic pain with painDETECT scores of 4.4±3.2, 2.9±2.9, and 1.5±2.0, respectively. There was a significant correlation between total postoperative morphine use during 48 hours after the surgery and a tendency to develop neuropathic pain (p=0.022). CONCLUSIONS: Chronic neuropathic pain was uncommon in AIS patients who had undergone PSF surgery. Higher opioid consumption will increase the possibility of developing chronic neuropathic pain.

Learning Curve for a Dual Attending Surgeon Strategy in Posterior Spinal Fusion (PSF): An Analysis of 105 Severe Adolescent Idiopathic Scoliosis Patients (Cobb Angle ≥90°).

STUDY DESIGN: Retrospective study. OBJECTIVE: To assess the learning curve of a dual attending surgeon strategy in severe adolescent idiopathic scoliosis patients. SUMMARY OF BACKGROUND DATA: The advantages of a dual attending surgeon strategy in improving the perioperative outcome in scoliosis surgery had been reported. However, the learning curve of this strategy in severe scoliosis had not been widely studied. METHODS: A total of 105 patients with adolescent idiopathic scoliosis with Cobb angle of 90° or greater, who underwent posterior spinal fusion using a dual attending surgeon strategy were recruited. Primary outcomes were operative time, total blood loss, allogeneic blood transfusion requirement, length of hospital stay from time of operation and perioperative complications. Cases were sorted chronologically into group 1: cases 1 to 35, group 2: cases 36 to 70, and group 3: case 71 to 105. Mean operative time (≤193.3 min), total blood loss (≤1612.2 mL), combination of both and allogeneic blood transfusion were the selected criteria for receiver operating characteristic analysis of the learning curve. RESULTS: The mean Cobb angle was 104.5°â€Š±â€Š12.3°. The operative time, total blood loss, and allogeneic blood transfusion requirement reduced significantly for group 1 (220.6 ±â€Š54.8 min; 2011.3 ±â€Š881.8 mL; 12 cases) versus group 2 (183.6 ±â€Š36.7 min; 1481.6 ±â€Š1035.5 mL; 3 cases) and group 1 versus group 3 (175.6 ±â€Š38.4 min; 1343.7 ±â€Š477.8 mL; 3 cases) (P < 0.05). There were six perioperative complications. Fifty-seven cases were required to achieve the preset criteria (mean operative time and mean total blood loss) (area under the curve 0.740; P < 0.001; sensitivity 0.675; specificity 0.662). CONCLUSION: There was significant improvement in operative time and total blood loss when comparing group 1 versus group 2 and group 1 versus group 3. The cut-off point for the learning curve was 57 cases when the preset criteria were fulfilled (≤193.3 min operative time and ≤1612.2 mL of total blood loss).Level of Evidence: 4.

Does Menses Affect the Risk of Blood Loss in Adolescent Idiopathic Scoliosis Patients Undergoing Posterior Spinal Fusion Surgeries?: A Propensity-Score Matching Study.

STUDY DESIGN: Retrospective propensity score matching study. OBJECTIVE: To investigate whether menses affect intraoperative blood loss in female adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) surgeries. SUMMARY OF BACKGROUND DATA: There were concerns whether patients having menses will have higher intraoperative blood loss if surgery were to be done during this period. METHODS: This study included 372 females who were operated between May 2016 to May 2019. Fifty-five patients had menses during surgery (Group 1, G1) and 317 patients did not have menses during surgery (Group 2, G2). Propensity score matching (PSM) analysis with one-to-one, nearest neighbor matching technique and with a match tolerance of 0.001 was used. The main outcome measures were intraoperative blood loss (IBL), volume of blood salvaged, transfusion rate, preoperative hemoglobin, preoperative platelet, preoperative prothrombin time, preoperative activated partial thromboplastin time (APTT), international normalized ratio (INR), and postoperative hemoglobin. Postoperative Cobb angle and correction rate were also documented. RESULTS: At the end of PSM analysis, 46 patients from each group were matched and balanced. The average operation duration for G1 was 140.8 ±â€Š43.0 minutes compared with 143.1 ±â€Š48.3 minutes in G2 (P = 0.806). The intraoperative blood loss for G1 was 904.3 ±â€Š496.3 mL and for G2 was 907.9 ±â€Š482.8 mL (P = 0.972). There was no significant difference in terms of normalized blood loss (NBL), volume of blood salvaged during surgery, preoperative hemoglobin, postoperative hemoglobin, hemoglobin drift, estimated blood volume (EBV), IBL per EBV and IBL per level fused (P > 0.05). No postoperative complications were encountered in both groups. On average, the postoperative hospital stay was 3.5 ±â€Š0.8 days for both groups (P = 0.143). CONCLUSION: Performing corrective surgery during the menstrual phase in female AIS patients is safe without risk of increased blood loss. LEVEL OF EVIDENCE: 4.

The Effect of 20-Minute Mindful Breathing on the Perception of Suffering and Changes in Bispectral Index Score (BIS) in Palliative Care Informal Caregivers: A Randomized Controlled Study.

Informal caregivers are at risk of being overwhelmed by various sources of suffering while caring for their significant others. It is, therefore, important for caregivers to take care of themselves. In the self-care context, mindfulness has the potential to reduce caregiver suffering. We studied the effect of a single session of 20-minute mindful breathing on the perceived level of suffering, together with the changes in bispectral index score (BIS) among palliative care informal caregivers. This was a randomized controlled study conducted at the University of Malaya Medical Centre, Malaysia. Forty adult palliative care informal caregivers were recruited and randomly assigned to either 20-minute mindful breathing or 20-minute supportive listening. The changes in perceived suffering and BIS were measured preintervention and postintervention. The reduction in suffering score in the intervention group was significantly more than the control group at minute 20 (U = 124.0, n1 = n2 = 20, mean rank1 = 24.30, mean rank2 = 16.70, z = -2.095, P = .036). The reduction in BIS in the intervention group was also significantly greater than the control group at minute 20 (U = 19.5, n1 = n2 = 20, mean rank1 = 29.52, mean rank2 = 11.48, z = -4.900, P < .0001). Twenty minutes of mindful breathing was more efficacious than 20 minutes of supportive listening in the reduction in suffering among palliative care informal caregivers.

Perioperative Outcome of Severe Idiopathic Scoliosis (Cobb Angle ≥ 90°): Is There Any Difference Between "Daytime" Versus "After-hours" Surgeries?

STUDY DESIGN: Retrospective study from a prospectively collected database. OBJECTIVE: To compare the perioperative outcome between after-hours and daytime surgery carried out by a dedicated spinal deformity team for severe Idiopathic Scoliosis (IS) patients with Cobb angle ≥ 90°. SUMMARY OF BACKGROUND DATA: There were concerns that after-hours corrective surgeries in severe IS have higher morbidity compared to daytime surgeries. METHODS: Seventy-one severe IS patients who underwent single-staged Posterior Spinal Fusion (PSF) were included. Surgeries performed between 08:00H and 16:59H were classified as "daytime" group and surgeries performed between 17:00H and 06:00H were classified as "after-hours" group. Perioperative outcome parameters were average operation start time and end time, operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, preoperative and postoperative hemoglobin, blood transfusion rate, total patient-controlled anesthesia (PCA) morphine usage, length of postoperative hospitalization, and complications. Radiological variables assessed were preoperative and postoperative Cobb angle, side bending flexibility, number of fusion levels, number of screws used, Correction Rate, and Side Bending Correction Index. RESULTS: Thirty patients were operated during daytime and 41 patients were operated after-hours. The mean age was 16.1 ±â€Š5.8 years old. The mean operation start time for daytime group was 11:31 ±â€Š2:45H versus 19:10 ±â€Š1:24H for after-hours group. There were no significant differences between both groups in the operation duration, intraoperative blood loss, intraoperative hemodynamic parameters, postoperative hemoglobin, hemoglobin drift, transfusion rate, length of postoperative hospitalization, postoperative Cobb angle, Correction Rate, and Side Bending Correction Index. There were four complications (1 SSEP loss, 1 massive blood loss, and 2 superficial wound infections) with no difference between daytime and after-hours group. CONCLUSION: After-hours elective spine deformity corrective surgeries in healthy ambulatory patients with severe IS performed by a dedicated spinal deformity team using dual attending surgeon strategy were as safe as those performed during daytime. LEVEL OF EVIDENCE: 4.