Which neonates should have a pre-operative echocardiography? Findings from a national survey and a retrospective tertiary single-centre analysis in the United Kingdom.

PURPOSE: The detection of congenital heart disease (CHD) before neonatal surgery is crucial for anaesthetic and perioperative management. There are no established criteria for pre-operative echocardiography in neonates. We aimed to survey current practice in the United Kingdom and evaluate the reliability of antenatal screening and postnatal clinical assessment in detecting CHD before surgery. METHOD: A 9-point questionnaire was sent to all paediatric surgical centres in the United Kingdom to assess their practice. Subsequently, a single-centre retrospective review of all neonatal surgery over 5 years (2015-2020) was conducted in our tertiary paediatric/neonatal hospital. Data included pre-operative clinical assessment, performance of chest radiograph and echocardiography. Indications for echocardiography were categorised and assessed using sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: All 26 paediatric surgical centres responded to our survey. 23/26 (88.5%) did not have established criteria or guidelines for pre-operative echocardiography. There was a large variation in which surgical conditions required a pre-operative scan and whether a normal clinical examination was considered sufficient to not require one. For the retrospective review, 454 patients were identified. There were 40 cases with CHDs (8.8%), 13 were classed as major or moderate. Indications for echocardiography were categorised into abnormal foetal cardiac screening, medical/surgical conditions associated with CHD and an abnormal cardiorespiratory examination. Sensitivity, specificity, positive predictive value and negative predictive value for major and moderate CHD were 46%, 99%, 67%, 98% for abnormal foetal screening, 46%, 97%, 35%, 98% for associated medical conditions, 62%, 66%, 6%, 98% for associated surgical conditions, and 100%, 66%, 9%, 100% for abnormal clinical examination. CONCLUSION: The use of pre-operative echocardiography in neonates is not standardised across the UK. The results from our cohort demonstrate that foetal echocardiography is not sufficient to capture all major and moderate CHDs, but the absence of abnormal clinical examination is highly reliable in ruling out them out. Specifying a list of medical/surgical of conditions associated with CHD warranting pre-operative echocardiography may improve yield, but this depends on the availability of resources and expertise.

Paediatric pre-operative anaesthetic clinic: A survey of consultant-led caseload and outcomes.

AIM: The role of pre-operative anaesthetic clinics (POAC) in adult practice is well-established and is developing in paediatric hospitals in the UK. METHODS: We carried out a retrospective survey of all patients assessed in our POAC by a consultant, determining the pre-operative problems and the perioperative anaesthetic interventions and outcomes. RESULTS: In 2016, 537 patients were seen by a consultant: the median age was 5.5 years (interquartile range 2.2-10.2) and median weight was 18.7 kg (interquartile range 12-28.7). 77% were ASA3 and 4% were ASA4. Seventy-five percent of patients referred for consultant assessment had a problem with at least one of the following four major body systems: cardiac (37%), respiratory (26%), airway (18%) and neurodevelopment (14%), Fifteen percent of these patients had two of these systems affected, and 3% had three or more. The rate of cancellation due to significant risk was 2.6% (n = 14): nine had significant cardiac risk and five had respiratory reasons. The rate of serious perioperative problems was 2.8% (n = 15): six were cardiac, six were respiratory, two neurological and one coagulation. Cardiac and airway problems occurred during anaesthesia, whereas problems relating to respiratory and neurological disease were post-operative. Of the 15 patients with three or more body system problems, 5 were cancelled or had a perioperative complication causing deterioration, 5 had a major complication but recovered fully and 5 proceeded to general anaesthesia (GA) without serious event. There were no deaths during GA or within 30 days. CONCLUSION: In the POAC, consultants identified a wide range of GA-related potential problems enabling patients to be investigated, informed and prepared (or cancelled because of excess risk), and for appropriate resources to be allocated to achieve efficient and safe perioperative care.

Anesthetic considerations for scoliosis surgery in a patient with recessive severe/lethal form of osteogenesis imperfecta.

Osteogenesis imperfecta is a heterogeneous genetic disorder characterized by bone fragility, with disease ranging from mild fractures to death in utero. We describe a child with autosomal recessive osteogenesis imperfecta type VIII (severe or lethal phenotype), who successfully underwent posterior spinal fusion, was extubated on postoperative day 1 and discharged home 25 days later. Recently identified recessive forms of osteogenesis imperfecta are associated with severe/lethal phenotype. Special consideration is needed in scoliosis surgery, with challenges arising from prone positioning, neurophysiology monitoring, and blood loss.

Mini-review: Evaluation and Management of Retroperitoneal Masses in Patients with Testicular Cancer.

Testicular germ cell tumours (GCTs) account for the majority of testicular malignancies. Seminomas and nonseminomas differ in prognosis and management strategies. While cisplatin-based chemotherapy has significantly improved survival rates, identification of residual masses after chemotherapy is crucial for determining further treatment and survival. For seminomas, spontaneous resolution of residual masses occurs in a significant percentage of cases. Fluorodeoxyglucose positron emission tomography (FDG PET) is recommended for evaluation of residual masses after chemotherapy. Retroperitoneal lymph node dissection (RPLND) offers therapeutic benefits but is challenging because of an increase in desmoplasia after chemotherapy. For nonseminomas, residual masses are common after chemotherapy, with surgical resection necessary for masses larger than 1 cm. FDG PET has limited utility, and timely surgical intervention is crucial for favourable outcomes. Teratoma, if left unresected, can lead to serious complications, including growing teratoma syndrome, malignant transformation, and late relapse. Extraretroperitoneal residual masses, particularly those containing teratoma, are associated with poorer prognosis. Surgical resection remains the mainstay treatment, with significantly higher progression-free and recurrence-free survival rates for fibrosis/necrosis in comparison to teratoma or viable cancer. Understanding the characteristics and management of residual masses after chemotherapy is paramount for optimising treatment strategies and improving patient outcomes in testicular GCT. PATIENT SUMMARY: We reviewed treatment options for patients with testicular cancer who still have tumour tissue in the lower abdomen after chemotherapy. Surgical removal of the tumour is the main option; removal of lymph nodes can also help, but may be difficult because of tissue reactions to chemotherapy. Survival rates differ according to the tumour type and are lower for tumours beyond the lower abdomen.

"Seeing Is Believing": Additive Utility of 68Ga-PSMA-11 PET/CT in Prostate Cancer Diagnosis.

Widespread adoption of mpMRI has led to a decrease in the number of patients requiring prostate biopsies. 68Ga-PSMA-11 PET/CT has demonstrated added benefits in identifying csPCa. Integrating the use of these imaging techniques may hold promise for predicting the presence of csPCa without invasive biopsy. A retrospective analysis of 42 consecutive patients who underwent mpMRI, 68Ga-PSMA-11 PET/CT, prostatic biopsy, and radical prostatectomy (RP) was carried out. A lesion-based model (n = 122) using prostatectomy histopathology as reference standard was used to analyze the accuracy of 68Ga-PSMA-11 PET/CT, mpMRI alone, and both in combination to identify ISUP-grade group ≥ 2 lesions. 68Ga-PSMA-11 PET/CT demonstrated greater specificity and positive predictive value (PPV), with values of 73.3% (vs. 40.0%) and 90.1% (vs. 82.2%), while the mpMRI Prostate Imaging Reporting and Data System (PI-RADS) 4-5 had better sensitivity and negative predictive value (NPV): 90.2% (vs. 78.5%) and 57.1% (vs. 52.4%), respectively. When used in combination, the sensitivity, specificity, PPV, and NPV were 74.2%, 83.3%, 93.2%, and 51.0%, respectively. Subgroup analysis of PI-RADS 3, 4, and 5 lesions was carried out. For PI-RADS 3 lesions, 68Ga-PSMA-11 PET/CT demonstrated a NPV of 77.8%. For PI-RADS 4-5 lesions, 68Ga-PSMA-11 PET/CT achieved PPV values of 82.1% and 100%, respectively, with an NPV of 100% in PI-RADS 5 lesions. A combination of 68Ga-PSMA-11 PET/CT and mpMRI improved the radiological diagnosis of csPCa. This suggests that avoidance of prostate biopsy prior to RP may represent a valid option in a selected subgroup of high-risk patients with a high suspicion of csPCa on mpMRI and 68Ga-PSMA-11 PET/CT.

Assessing Elevated Blood Glucose Levels Through Blood Glucose Evaluation and Monitoring Using Machine Learning and Wearable Photoplethysmography Sensors: Algorithm Development and Validation.

BACKGROUND: Diabetes mellitus is the most challenging and fastest-growing global public health concern. Approximately 10.5% of the global adult population is affected by diabetes, and almost half of them are undiagnosed. The growing at-risk population exacerbates the shortage of health resources, with an estimated 10.6% and 6.2% of adults worldwide having impaired glucose tolerance and impaired fasting glycemia, respectively. All current diabetes screening methods are invasive and opportunistic and must be conducted in a hospital or laboratory by trained professionals. At-risk participants might remain undetected for years and miss the precious time window for early intervention to prevent or delay the onset of diabetes and its complications. OBJECTIVE: We aimed to develop an artificial intelligence solution to recognize elevated blood glucose levels (≥7.8 mmol/L) noninvasively and evaluate diabetic risk based on repeated measurements. METHODS: This study was conducted at KK Women's and Children's Hospital in Singapore, and 500 participants were recruited (mean age 38.73, SD 10.61 years; mean BMI 24.4, SD 5.1 kg/m2). The blood glucose levels for most participants were measured before and after consuming 75 g of sugary drinks using both a conventional glucometer (Accu-Chek Performa) and a wrist-worn wearable. The results obtained from the glucometer were used as ground-truth measurements. We performed extensive feature engineering on photoplethysmography (PPG) sensor data and identified features that were sensitive to glucose changes. These selected features were further analyzed using an explainable artificial intelligence approach to understand their contribution to our predictions. RESULTS: Multiple machine learning models were trained and assessed with 10-fold cross-validation, using participant demographic data and critical features extracted from PPG measurements as predictors. A support vector machine with a radial basis function kernel had the best detection performance, with an average accuracy of 84.7%, a sensitivity of 81.05%, a specificity of 88.3%, a precision of 87.51%, a geometric mean of 84.54%, and F score of 84.03%. CONCLUSIONS: Our findings suggest that PPG measurements can be used to identify participants with elevated blood glucose measurements and assist in the screening of participants for diabetes risk.

Poor utility of current nomograms assessing the risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma and proposal of a new model.

BACKGROUND: The Memorial Sloan Kettering Cancer Center nomogram, the predictive scoring system of Yamamoto et al, and the 3-point transfusion risk score of Lemke et al are models used to determine the probability of receiving intraoperative blood transfusion in patients undergoing liver resection. However, the external validity of these models remains unknown. The objective of this study was to evaluate their predictive performance in an external cohort of patients with hepatocellular carcinoma. We also aimed to identify predictors of blood transfusion and develop a new predictive model for blood transfusion. METHODS: Post hoc analysis of our prospective database of 1,081 patients undergoing liver resection for hepatocellular carcinoma from 2001 to 2018. The predictive performance of current prediction models was evaluated using C statistics. Demographic and clinical variables as predictors of blood transfusion were assessed. Using logistic regression, an alternative model was created. RESULTS: The Lemke transfusion risk score performed better than the Memorial Sloan Kettering Cancer Center nomogram (0.69, 95% confidence interval 0.66-0.73 vs 0.66, 95% liver resection 0.62-0.69) (P < .001). The model from Yamamoto et al performed comparably with no statistically significant differences found through pairwise comparison. In our alternative model, hemoglobin level, albumin level, liver resection type, and tumor size were independent predictors of blood transfusion. The new HATS model obtained a C statistic of 0.74 (95% confidence interval 0.71-0.78), performing significantly better than the previous 3 models (P ≤ 0.001 for all). CONCLUSION: The existing Memorial Sloan Kettering Cancer Center, Yamamoto et al, and Lemke et al had nomograms with the suboptimal accuracy of predicting risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma. The proposed HATS model was more accurate at predicting patients at risk of blood transfusion.

Failure of hospital employees to comply with smoke-free policy is associated with nicotine dependence and motives for smoking: a descriptive cross-sectional study at a teaching hospital in the United Kingdom.

BACKGROUND: Smoke-free policy aims to protect the health of the population by reducing exposure to environmental tobacco smoke (ETS), and World Health Organisation (WHO) guidance notes that these policies are only successful if there is full and proper enforcement. We aimed to investigate the problem of resistance to smoking restrictions and specifically compliance with smoke-free policy. We hypothesised that an explanation for non-compliance would lie in a measurable difference between the smoking behaviours of compliant and non-compliant smokers, specifically that non-compliance would be associated with nicotine dependence and different reasons for smoking. METHODS: We conducted a questionnaire-based, descriptive, cross-sectional study of hospital employees. Seven hundred and four members of staff at Addenbrooke's Hospital, Cambridge, UK, completed the questionnaire, of whom 101 were smokers. Comparison between compliant and non-compliant smokers was made based on calculated scores for the Fagerström test and the Horn-Waingrow scale, and level of agreement with questions about attitudes. For ordinal data we used a linear-by-linear association test. For non-parametric independent variables we used the Mann-Whitney test and for associations between categorical variables we used the chi-squared test. RESULTS: The demographic composition of respondents corresponded with the hospital's working population in gender, age, job profile and ethnicity. Sixty nine smokers reported they were compliant while 32 were non-compliant. Linear-by-linear association analysis of the compliant and non-compliant smokers' answers for the Fagerström test suggests association between compliance and nicotine dependence (p = 0.049). Mann-Whitney test analysis suggests there is a statistically significant difference between the reasons for smoking of the two groups: specifically that non-compliant smokers showed habitual smoking behaviour (p = 0.003). Overall, compliant and non-compliant smokers did not have significantly different attitudes towards the policy or their own health. CONCLUSION: We demonstrate that those who smoke in this setting in contravention to a smoke-free policy do so neither for pleasure (promotion of positive affect) nor to avoid feeling low (reduction of negative affect); instead it is a resistant habit, which has little or no influence on the smoker's mood, and is determined in part by chemical dependence.