Surgical and Oncological Outcome of Laparoscopic Resection of Colorectal Cancers: A Single-Center Experience.

BACKGROUND: Laparoscopy is one of the major advances in surgery in the last 30 years and has many benefits. Although laparoscopy was initially used for resection of benign colon lesions, it is now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both the surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections. METHODS: In 2013, a laparoscopic colorectal resection service was established in northern Iraq at Zheen Hospital, Erbil. Data from all consecutive colorectal cancers were collected. Patients with locally advanced diseases and those who required emergency operations for bowel obstruction or perforation were excluded. We analyzed demographic, operative, postoperative, and histopathological data for all patients who were included in the study. RESULTS: A total of 124 patients with colorectal cancers presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of the patients was 54.5 years. The majority of patients were men (n=62; 55.4%). In 39 patients (35%), the cancer was located in the sigmoid; in 33 patients (29.5%) the cancer was in the rectum. Laparoscopic anterior resection was the most common procedure (n=50; 45%), followed by right hemicolectomy in 17 cases (15.1%). The conversion rate to open surgery was 8% (nine cases). The most common causes of conversion to open surgery were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes and the mean hospital stay was three days. No complications were reported in 94 patients (84%). Among the complications, wound infection was seen in seven patients (7.8%). There were six anastomotic leaks (6.7%). The mean number of lymph nodes harvested was 13. In 70 patients (62.5%), the lymph node count was ≥12 with a median of 13. The mean distal resection margin was 6 cm and 2.5 cm for colon and rectal resections, respectively. CONCLUSION: This study reveals that laparoscopic resection for colorectal cancers is surgically practicable and safe with the benefits of a short hospital stay, adequate resection margins, and adequate lymph node yield.

Propofol-induced hippocampal Neurotoxicity: A mitochondrial perspective.

Propofol is a frequently used anesthetic. It can induce neurodegeneration and inhibit neurogenesis in the hippocampus. This effect may be temporary. It can, however, become permanent in vulnerable populations, such as the elderly, who are more susceptible to Alzheimer's disease, and neonates and children, whose brains are still developing and require neurogenesis. Current clinical practice strategies have failed to provide an effective solution to this problem. In addition, the molecular mechanism of this toxicity is not fully understood. Recent advances in molecular research have revealed that apoptosis, in close association with mitochondria, is a crucial mechanism through which propofol contributes to hippocampal toxicity. Preventing the toxicity of propofol on the hippocampus has shown promise in in-vivo, in-vitro, and to a lesser extent human studies. This study seeks to provide a comprehensive literature review of the effects of propofol toxicity on the hippocampus via mitochondria and to suggest translational suggestions based on these molecular results.

Falsely prolonged prothrombin time test in a patient with erythrocytosis: a case report.

The prothrombin time (PT) test is commonly used to monitor deficiencies in coagulation factors. A prolonged PT may indicate a deficiency of factors II, V, VII, X, and fibrinogen, or the presence of an inhibitor. However, further tests are required to differentiate between a true factor deficiency and the presence of an inhibitor. It is important to note that falsely prolonged PT can lead to misdiagnosis and inappropriate clinical intervention that can have life-threatening consequences. A 19-year-old woman with elevated hematocrit levels and prolonged PT was diagnosed with secondary erythrocytosis due to cyanotic congenital heart disease with ventricular septal defect (VSD). However, further investigation revealed that the prolonged PT result was false. Excess citrate in the blood sample, caused by polycythemia, led to this misleading outcome, resulting in unnecessary and potentially harmful treatment. This incident emphasizes the importance of laboratory personnel and clinicians being aware of the test's limitations. Not only should specialists in thrombosis and hemostasis possess this knowledge, but it is also pertinent for general laboratory staff, as well as laboratory directors and specialists. The significance of accurate laboratory testing for the proper diagnosis and treatment of patients is highlighted in this case.

The environmental impact of heavy metals in sediments of main valleys in the eastern side of Mosul City, Iraq.

Analyzing the geochemical changes in stream sediments can reveal important surface processes on Earth, like weathering, transportation, and cation exchange. The study area is located on the eastern side of Mosul, where valleys named Al-Rashediya, Al-Kharrazi, Al-Khosar, Al-Danffilli, and Al-Shor flow towards the Tigris River. These valleys' sediments contain diverse components like clay minerals, organic matter, iron oxides, carbonates, and heavy metals (H.M.s), either as part of these substances or adsorbed onto them. In this study, 36 sediment samples were gathered from these valleys. They underwent chemical analysis through X-ray fluorescence to ascertain their chemical constituents of major oxides. To understand the distribution of H.M.s in these sediments, correlation coefficient analysis and factor analysis were utilized. The study employed the geoaccumulation index (Igeo) and enrichment factor (E.F.) to evaluate sediment contamination. The results of Igeo ranged from Cr = 0.24 to 1.83, Ni = -0.92 to 0.77, Cu = -2.41 to 0.05, Zn = -1.83 to 0.89, Pb = -1.54 to 0.36, and As = -2.84 to 0.80. These findings suggest that the valley sediments are generally in the range of deficiency to minimal enrichment and moderate enrichment. However, Al-Danffilli Valley shows strong contamination levels for Cu, Zn, and Pb. The E.F. values for Cr = 3.63-12.50, Ni = 1.95-4.19, Cu = 0.69-12.36, Zn = 1.08-16.19, Pb = 1.25-62.16, and As = 0.60-1.79 indicate levels ranging from deficiency to minimal and moderate enrichment. Al-Danffilli Valley, in particular, was identified as ranging from moderate to extremely high enrichment, attributed to its location near industrial areas and its tributaries.

Attitudes of Anesthesiology Postgraduate Residents Toward the Influential Factors in Their Success in the Iranian National Board Exam.

Background: One of the prominent indicators of academic success in postgraduate medical education is the "Residents' Pass Rate" in the "National Board Exam." Objectives: This study was designed and implemented to assess the attitudes of the anesthesiology residents toward factors affecting their success in the National Board Exam. Methods: After the Institutional Review Board (IRB) approval, in an attitude assessment study, 20 of the 21 recently graduated anesthesiology residents were asked about the factors affecting their success quantitatively and qualitatively. A self-administered questionnaire with 19 closed questions and a personal virtual WhatsApp Messenger® interview were used for the study. Results: The respondents' viewpoints demonstrated that a step-by-step multifaceted integrative program in combination with psychological support (both from the family and the department) and individual motivation positively affected their success and their endurance to overcome the high load of the mandatory texts. In contrast, unplanned stressors leading to program shifts (mainly due to COVID-19) had adverse effects on their success. Conclusions: Anesthesiology residents believed that a well-designed and appropriately implemented study plan with psychological support and personal motivating factors could facilitate passing the National Board Exam, and unplanned external stressors could hinder it.

Virtual faculty development program in bioethics evaluated by Kirkpatrick model: A unique opportunity.

BACKGROUND: With a shortage of teachers willing to deliver bioethics courses, particularly during the COVID-19 pandemic, faculty development in bioethics has become increasingly important for capacity building in medical education. This study aims to determine the impact of an online course on faculty development in teaching bioethics. METHODS: This quasi-experimental study involved twenty-six multidisciplinary faculty members who participated in an online bioethics course from January 4th to 22nd, 2022. Kirkpatrick's evaluation model was used to assess the participants' reactions, knowledge, and behavior, using online questionnaires and direct observation by expert faculty. SPSS 25 was used for data analysis. RESULTS: The Kirkpatrick evaluation model showed that the course was highly satisfactory in terms of content and delivery, with a significant improvement in clinical faculty's knowledge from pre-test to post-test (14.18 ± 1.601 to 16 ± 2.049, p < 0.05). The participants demonstrated an improved range of teaching and learning methods. CONCLUSION: The online course on bioethics successfully improved the clinical faculty's knowledge and overall approach to teaching bioethics. These findings highlight the importance of well-constructed faculty development programs, particularly during times of resource constraint such as the COVID-19 pandemic.

Congenital Bleeding Disorders and COVID-19-A Systematic Literature Review.

Hypercoagulability is a prominent feature of coronavirus disease 2019 (COVID-19) and can lead to fatal consequences. Although the impact of COVID-19 on several disorders is well-established, its effect on congenital bleeding disorders (CBDs) is not well-documented. To address this ambiguity, a systematic review was conducted on the available studies to determine the impact of COVID-19 and vaccination aimed to prevent COVID-19 on patients with CBDs. We performed a systematic literature review using relevant keywords and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. We conducted our search on the PubMed, Scopus, and Web of Science databases until July 2023. Out of 31 included studies, 12 case series covering 770 patients with CBD and COVID-19 were further analyzed. The majority of the patients had hemophilia A (n = 352, ∼46%) or hemophilia B (n = 74, ∼10%), while the remaining patients had von Willebrand disease (n = 43, 5.6%) or rare bleeding disorders (n = 27, 3.5%). A total of 25 deaths (3.2%) and 22 intensive care unit admissions (2.8%) were recorded. Bleeding complications were reported in the majority of the 12 case series (n = 7, 58.3%) and in most of the case reports (n = 8, ∼57%), while thrombotic complications were only reported in two studies (16.6%). The mortality rate ranged from 0% in five studies (41.6%) to 5.7% and the rate of hospitalization ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the thrombotic complication rate in one study was 6.9%. The mortality rate varied from 0 to 5.7%, and the hospitalization rate ranged from 0 to 40%. Bleeding complications were reported in a range of 0 to 81%, while the rate of thrombotic complications in one study was 6.9%. Vaccination was reported in five case series, which included 821 patients with CBDs with the majority having hemophilia A (n = 479; 67.2%) and hemophilia B (n = 85; ∼12%). The most frequently reported side effects were myalgia (6.5%), flu-like symptoms (4.8%), fever (4.7%), and headache (4%). COVID-19 in patients with CBDs appears to provoke thrombotic complications and bleeding events more frequently, as well as a higher rate of hospitalization, which may be partially due to the increased risk of bleeding events. Although it seems that patients with CBD have lower mortality rates, further studies are necessary to fully understand this, especially considering comorbidities and low number of available studies.

Porosity Effects on Static Performance of Carbon Nanotube-Reinforced Meta-Nanocomposite Structures.

A mixture of outstanding merits of polymer nanocomposites (PNCs) and metamaterials can lead to the development of ultra-light meta-nanomaterials whose high sensitivity can be efficiently used in wearable strain sensors. Thus, reliable data about the performance of structural elements manufactured from such meta-nanomaterials are needed before implementing their design. Motivated by this issue, the negative impacts of pores in the microstructure and carbon nanotubes' (CNTs') wavy configuration on the nonlinear bending features of thick beams consisted of auxetic CNT-reinforced (CNTR) polymers are probed for the first time. The impacts of distinct porosity distributions on the mechanical reaction of the system are covered in this article. In addition, a very low computationally cost homogenization is implemented herein to consider the waviness' influence on the reinforcement mechanism in the auxetic PNC material. Moreover, higher-order shear deformation theory (HSDT) is followed and merged with non-linear definition of strain tensor with the aid of von Kármán's theory to gather the equations describing the problem. Thereafter, the famous Navier's exact solution is employed towards solving the problem for thick beams with simple supports at both ends. A comparison of our data with those existing in the literature certifies the accuracy of the presented modeling. The outcomes indicate on the remarkable rise in the flexural deformation of the auxetic PNC beam while the coefficient of porosity is raised. It is also shown that utilization of thick-walled cells in the re-entrant lattice can help to control the system's total deflection. In addition, if the non-ideal shape of the nanofillers is ignored, the deflection of the meta-nanomaterial beam will be much larger than that of ideal calculations.

Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial.

BACKGROUND: In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a nonsignificant 16% reduction in 30-day composite of venous/arterial thrombosis or death in intensive care unit (ICU) patients with COVID-19. Thrombo-inflammatory response in coronavirus disease 2019 (COVID-19) may last beyond the first 30 days. METHODS: This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this prespecified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with the Post-COVID-19 Functional Scale. RESULTS: In the primary analysis, 587 patients were included (age: 57 [Q1-Q3: 45-68] years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio [HR]: 0.80, 95% confidence interval [CI]: 0.60-1.05, p = 0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, p interaction = 0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (ORordinal: 0.64, 95% CI: 0.41-1.01, p = 0.05). CONCLUSION: Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset (NCT04486508).

The Neuroprotective Effects of Administration of Methylprednisolone in Cardiopulmonary Resuscitation in Experimental Cardiac Arrest Model.

Although advances in diagnosis and treatment of cardiac arrest (CA) could improve neurological outcomes after cardiopulmonary resuscitation (CPR), survival rate and neurological outcome after CA and CPR remain poor. This study aimed to investigate the effect of epinephrine (EP) alone and EP in combination with methylprednisolone (MP) (EP + MP) on some the apoptotic and anti-apoptotic genes and proteins levels expression of the cerebral cortex as well as neuronal death in a CA rat model. Forty-five male Sprague Dawley rats were randomly divided into three groups including the hypoxic CA + EP, hypoxic CA + EP + MP, and sham groups using a simple randomization procedure. In both hypoxic CA groups, CA was induced by asphyxia and immediately after confirmation of CA, the treatment strategies including chest compression or cardiac massage simultaneously with ventilation, and administration of EP alone (20 mg/kg, every 3 min) and EP (20 mg/kg, every 3 min) + 30 (mg/kg) of MP were done. The sham group only received anesthetic drugs without CA. Some neurological outcomes were investigated using histopathological, immunohistochemical, molecular, and terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) assays at 5 and 48 h post-CPR. The data obtained showed the highest up-regulation of apoptotic genes and proteins expression, the lowest expression of anti-apoptotic gene and protein expression, the most DNA fragmentation and histopathological changes belonged to the EP group on 48 h post-CPR. While mild and intermediate histopathological changes, DNA fragmentation and apoptotic activity was detected in theEP alone and EP + MP groups at 5 h and 48 h post-CPR, respectively. As a novel finding, the present study showed that EP + MP protects neurons from death provoked/induced by hypoxia and reperfusion injury in an experimental model of CA through up and down-regulation of pro- (caspases 3 and 8) and anti-apoptotic (BCL2) molecules, respectively.

Molecular basis of rare congenital bleeding disorders.

Rare bleeding disorders (RBDs), including factor (F) I, FII, FV, FVII, combined FV and FVIII (CF5F8), FXI, FXIII and vitamin-K dependent coagulation factors (VKCF) deficiencies, are a heterogeneous group of hemorrhagic disorder with a variable bleeding tendency. RBDs are due to mutation in underlying coagulation factors genes, except for CF5F8 and VKCF deficiencies. FVII deficiency is the most common RBD with >330 variants in the F7 gene, while only 63 variants have been identified in the F2 gene. Most detected variants in the affected genes are missense (>50% of all RBDs), while large deletions are the rarest, having been reported in FVII, FX, FXI and FXIII deficiencies. Most were located in the catalytic and activated domains of FXI, FX, FXIII and prothrombin deficiencies. Understanding the proper molecular basis of RBDs not only can help achieve a timely and cost-effective diagnosis, but also can help to phenotype properties of the disorders.

Wave Dispersion Behaviors of Multi-Scale CNT/Glass Fiber/Polymer Nanocomposite Laminated Plates.

In this paper, wave propagation in multi-scale hybrid glass fiber (GF)/carbon nanotube (CNT)/polymer nanocomposite plates is studied for the first time by means of refined higher-order plate theory. The hybrid nanocomposite consists of CNTs and glass fibers (GF) as reinforcing components distributed within a polymeric matrix. A hierarchical micromechanical approach is used to predict the effective mechanical properties of the hybrid nanocomposite, including the three-dimensional (3D) Mori-Tanaka method and the rule of mixture. Moreover, a refined-type higher-order shear deformation theory (HSDT) is implemented to take into account the influence of the shear deformation on the motion equations of the system. Then, the governing equations are achieved on the basis of the energy-based Hamilton's principle. Finally, the derived equations will be solved analytically for the purpose of extracting the natural frequency of the continuous system. A set of numerical examples are provided to cover the effects of various parameters on the wave dispersion characteristics of the plate. It can be declared that the hybrid nanocomposite system can achieve higher wave frequencies compared with other types of composite structures. Additionally, it is found that the selection of the lay-ups and length-to-diameter ratio plays a significant role in the determination of the sandwich plate's acoustic response.

Inhibitory Effects of Dutasteride on TLR4: An In vitro Pain Study.

Dutasteride was potentially proposed to control chronic pain by Toll-Like Receptor 4 (TLR4) inhibition through its effect on TLR4 expression, Myeloid differentiation primary response 88 (MyD88), Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), secretory Interleukin-1ß (IL-1ß), and nitric oxide (NO) in the Lipopolysaccharides (LPS)-stimulated U-87 MG cell line. Human astrocytoma U-87 MG cell line was cultured and incubated with 10 µg/mL of LPS for 24 hours to create a neuro-inflammation model, using two different treatment approaches. The first approach included LPS treatment for 24 hours, followed by dutasteride (20 µg/mL) incubation for the next 72 hours. In the second treatment approach, the cells were co-incubated with LPS and dutasteride for 72 hours. Expression of TLR4, MyD88, NF-κBp65, and secretory IL-1 was evaluated by Western blotting while expression of NO was assessed by NO assay. TLR4, MyD88, NF-κBp65, and secretory IL-1ß levels increased in LPS-treated cells after 24 hours. Dutasteride significantly decreased the secretion of NO and also, the levels of TLR4, MyD88, and NF-κBp65 in both treatment approaches. No difference in IL-1ß level was seen with the second treatment approach. Dutasteride has anti-inflammatory properties and probably analgesic effects, by mechanisms different from conventional analgesics.

Effects of Acute Potassium Chloride Administration on Ventricular Dysrhythmias after Myocardial Infarction in a Rat Model of Ischemia/Reperfusion.

Background: Acute myocardial infarction is an important cause of morbidity. This study aimed to investigate the effects of the administration of potassium chloride (KCl) on reperfusion-induced injuries in a rat model of myocardial ischemia/reperfusion. Methods: Thirty-six male Wistar rats, weighing 200 to 250 g, were randomly assigned to 3 experimental groups: control, K1 (10 µg/kg of KCl), and K2 (20 µg/kg of KCl). Twenty minutes before ischemia, a single dose of 10 and 20 µg/kg of KCl was intraperitoneally administered in the K1 and K2 groups, respectively. The coronary artery was occluded for 30 minutes (ischemia); thereafter, it was opened for 60 minutes (reperfusion) to measure hemodynamic parameters and ventricular arrhythmias. Blood sampling was performed after the reperfusion period to determine the serum levels of lactate dehydrogenase, troponin I, creatine kinase (CK)-MB, malondialdehyde, and pro-oxidant-antioxidant balance. Results: Serological parameters significantly decreased in the potassium groups compared with the control group. In particular, the decline was more pronounced for the serum levels of lactate dehydrogenase (1180.25±69.48 vs 1556.67±77.02 U/L; P=0.011), troponin I (21.98±0.61 vs 28.76±1.65 ng/mL; P=0.020), and pro-oxidant-antioxidant balance (15.51±0.72 vs 20.63±1.42 HK; P=0.041) in the K2 group compared with the K1 group. Moreover, the administration of 20 µg/kg of KCl significantly decreased the incidence of ventricular tachycardias and fibrillations compared with the control group (P=0.002). Additionally, no considerable differences were observed between the control group and the groups with 10 µg/kg and 20 µg/kg of KCl regarding the number of ventricular ectopic beats. Conclusion: The administration of KCl before ischemia could reduce ventricular arrhythmias and reperfusion-induced injuries by reducing oxidative stress.

Objective structured clinical examination: Challenges and opportunities from students' perspective.

BACKGROUND: Objective structured clinical examination (OSCE) has been used in evaluating clinical competence in health professions education around the world. Despite its implementation in Iraq for around a decade, limited studies investigated the challenges and opportunities to improve the standard and quality of this examination from student's perspective. METHODS: This qualitative study was based on an online open-ended questionnaire survey that was carried out in the College of Medicine, Hawler Medical University, Iraq at the beginning of the 2018-2019 academic year. A convenience sample of 180 students in the clinical phase (4th, 5th, and 6th) year of study were invited to participate. RESULTS: A total of 141 students responded to the online questionnaire. The participants were generally happy with the OSCE, and they recognized many positive aspects, including the role of the OSCE in increasing confidence, engagement and motivating learning, the role of the OSCE in achieving a higher level of learning, the content validity of the OSCE, and the quality of the OSCE. The main weak points of the OSCE identified by the students included unfairness, gender discrimination, duration of the OSCE, and the behavior of the examiners. Suggestions to improve the OSCE examination included improving the examiners' behavior, with the focus on the training of the examiners, and avoiding discrimination among students. CONCLUSIONS: Most of the students were generally satisfied with the current OSCE examination. The main concern of the students was related to the organization of the OSCE. Valuable suggestions were raised to improve the OSCE quality including examiners' and simulated patients' training.

Students and examiners perception on virtual medical graduation exam during the COVID-19 quarantine period: A cross-sectional study.

BACKGROUND: With the emergence of the COVID-19 pandemic and lockdown approach that was adopted all over the world, conducting assessments while maintaining integrity became a big challenge. This article aims at sharing the experience of conducting an online assessment with the academic community and to assess its effectiveness from both examiners' and students' perspectives. METHODS: An online assessment was carried out for the final year medical students of Hawler Medical University/Iraq during the lockdown period of the COVID-19 pandemic, June 2020. Then, an online questionnaire was sent to a sample of 61 examiners and 108 students who have been involved in evaluating the mentioned assessment process. Mann-Whitney and Kruskal-Wallis tests were used to compare the mean ranks of the overall satisfaction scores between categories of the students and examiners. Categorical data were summarized and presented as frequencies and percentages. RESULTS: The response rates among examiners and students were 69.4% and 88.5% respectively. The majority of the examiners were generally satisfied with the online examination process compared to only around a third of the students. However, both examiners and students agreed that online examination was not suitable for assessing the physical examination skills. CONCLUSION: The online assessment can be considered a good alternative and acceptable method for medical students' assessment in unpredicted emergencies, yet it was not applicable in testing physical examination skills.

Interruption of the Right Pulmonary Artery in a Neonate.

Interruption of the right pulmonary artery is a very rare anomaly which can be associated with other congenital heart lesions or can occur in isolation. Clinical presentations of the unilateral interruption of a pulmonary artery are varied including pulmonary hypertension, recurrent infection, dyspnea, exercise intolerance, hemoptysis, and chest pain. Less commonly, patients may be asymptomatic. Diagnosis of this anomaly is made by echocardiography and CT angiography as well as cardiac MRI. Treatment options are medical versus surgical management and often recommended in symptomatic patients with pulmonary hypertension, recurrent infection, and hemoptysis. Herein, we describe a very rare case of right pulmonary artery originating from the right subclavian artery in a 12-day-old neonate.

The Predictive Power of Near-Infrared Spectroscopy in Improving Cognitive Problems in Patients Undergoing Brain Surgeries: A Systematic Review.

One of the main objectives in neurosurgical procedures is the prevention of cerebral ischemia and hypoxia leading to secondary brain injury. Different methods for early detection of intraoperative cerebral ischemia and hypoxia have been used. Near-infrared spectroscopy (NIRS) is a simple, non-invasive method for monitoring cerebral oxygenation increasingly used today. The aim of this study was to systematically review the brain monitoring with NIRS in neurosurgery. The search process resulted in the detection of 324 articles using valid keywords on the electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, the full texts of 34 studies were reviewed, and finally 11 articles (seven prospective studies, three retrospective studies, and one randomized controlled trial) published from 2005 to 2020 were identified as eligible for systematic review. Meta-analysis was not possible due to high heterogeneity in neurological and neurosurgical conditions of patients, expression of different clinical outcomes, and different standard reference tests in the studies reviewed. The results showed that NIRS is a non-invasive cerebral oximetry that provides continuous and measurable cerebral oxygenation information and can be used in a variety of clinical settings.

Intermediate-Dose versus Standard-Dose Prophylactic Anticoagulation in Patients with COVID-19 Admitted to the Intensive Care Unit: 90-Day Results from the INSPIRATION Randomized Trial.

BACKGROUND: Thrombotic complications are considered among the main extrapulmonary manifestations of coronavirus disease 2019 (COVID-19). The optimal type and duration of prophylactic antithrombotic therapy in these patients remain unknown. METHODS: This article reports the final (90-day) results of the Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) study. Patients with COVID-19 admitted to intensive care were randomized to intermediate-dose versus standard-dose prophylactic anticoagulation for 30 days, irrespective of hospital discharge status. The primary efficacy outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause death. The main safety outcome was major bleeding. RESULTS: Of 600 randomized patients, 562 entered the modified intention-to-treat analysis (median age [Q1, Q3]: 62 [50, 71] years; 237 [42.2%] women), of whom 336 (59.8%) survived to hospital discharge. The primary outcome occurred in 132 (47.8%) of patients assigned to intermediate dose and 130 (45.4%) patients assigned to standard-dose prophylactic anticoagulation (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.95-1.55, p = 0.11). Findings were similar for other efficacy outcomes, and in the landmark analysis from days 31 to 90 (HR: 1.59, 95% CI: 0.45-5.06). There were 7 (2.5%) major bleeding events in the intermediate-dose group (including 3 fatal events) and 4 (1.4%) major bleeding events in the standard-dose group (none fatal) (HR: 1.82, 95% CI: 0.53-6.24). CONCLUSION: Intermediate-dose compared with standard-dose prophylactic anticoagulation did not reduce a composite of death, treatment with ECMO, or venous or arterial thrombosis at 90-day follow-up.

Prediction of Acute Kidney Injury After Cardiac Surgery Using Interpretable Machine Learning.

Background: Acute kidney injury (AKI) is a complication that occurs for various reasons after surgery, especially cardiac surgery. This complication can lead to a prolonged treatment process, increased costs, and sometimes death. Prediction of postoperative AKI can help anesthesiologists to implement preventive and early treatment strategies to reduce the risk of AKI. Objectives: This study tries to predict postoperative AKI using interpretable machine learning models. Methods: For this study, the information of 1435 patients was collected from multiple centers. The gathered data are in six categories: demographic characteristics and type of surgery, past medical history (PMH), drug history (DH), laboratory information, anesthesia and surgery information, and postoperative variables. Machine learning methods, including support vector machine (SVM), multilayer perceptron (MLP), decision tree (DT), random forest (RF), logistic regression, XGBoost, and AdaBoost, were used to predict postoperative AKI. Local interpretable model-agnostic explanations (LIME) and the Shapley methods were then leveraged to check the interpretability of models. Results: Comparing the area under the curves (AUCs) obtained for different machine learning models show that the RF and XGBoost methods with values of 0.81 and 0.80 best predict postoperative AKI. The interpretations obtained for the machine learning models show that creatinine (Cr), cardiopulmonary bypass time (CPB time), blood sugar (BS), and albumin (Alb) have the most significant impact on predictions. Conclusions: The treatment team can be informed about the possibility of postoperative AKI before cardiac surgery using machine learning models such as RF and XGBoost and adjust the treatment procedure accordingly. Interpretability of predictions for each patient ensures the validity of obtained predictions.