Evaluating the Efficacy of Perfusion MRI and Conventional MRI in Distinguishing Recurrent Cerebral Metastasis from Brain Radiation Necrosis.

Differentiating recurrent cerebral metastasis (CM) from brain radiation necrosis (BRN) is pivotal for guiding appropriate treatment and prognostication. Despite advances in imaging techniques, however, accurately distinguishing these conditions non-invasively is still challenging. This single-center retrospective study reviewed 32 cases (28 patients) with confirmed cerebral metastases who underwent surgical excision of lesions initially diagnosed by MRI and/or MR perfusion scans from 1 January 2015 to 30 September 2020. Diagnostic accuracy was assessed by comparing imaging findings with postoperative histopathology. Conventional MRI accurately identified recurrent CM in 75% of cases. MR perfusion scans showed significantly higher mean maximum relative cerebral blood volume (max. rCBV) in metastasis cases, indicating its potential as a discriminative biomarker. No single imaging modality could definitively distinguish CM from BRN. Survival analysis revealed gender as the only significant factor affecting overall survival, with no significant survival difference observed between patients with CM and BRN after controlling for confounding factors. This study underscores the limitations of both conventional MRI and MR perfusion scans in differentiating recurrent CM from BRN. Histopathological examination remains essential for accurate diagnosis. Further research is needed to improve the reliability of non-invasive imaging and to guide the management of patients with these post-radiation events.

Postoperative lordosis distribution index, patient reported outcome measures, and revision surgery following transforaminal lumbar interbody fusion.

Objective: Lordosis Distribution Index (LDI) is a new radiographic parameter associated with postoperative residual symptoms in patients undergoing Transforaminal Lumbar Interbody Fusion (TLIF). Recently, it has been applied on patients undergoing instrumented spine surgery, however not correlated to Patient Related Outcome Measures (PROMs). This study investigates whether the obtained the postoperative LDI after TLIF surgery correlates with the clinical outcome measured with PROMs. Methods: This study was based on prospectively obtained data in patients undergoing TLIF throughout 2017 at a Danish university hospital. Medical records and the DaneSpine Database were accessed to obtain preoperative, operative and follow-up data. Primary outcome was Oswestry Disability Index (ODI) 12 months postoperatively. Secondary outcomes included revision rate and additional PROMs. Results: 126 patients were included. 70 patients were classified with normolordosis (56 %), 42 hypolordosis (33 %) and 14 hyperlordosis (11 %). All groups experienced significant radiological changes undergoing surgery. Average reduction in ODI at 12 months postoperatively was -15.3 (±20.0). Minimally clinical important difference was achieved in 68 patients (54.0 %). No significant difference in PROMs between LDI-groups was observed in unadjusted or adjusted analyses. Revision surgery was performed in 8 patients with normolordosis (11.4 %), 7 hypolordosis (16.7 %) and 4 hyperlordosis (28.6 %). Conclusions: We found no significant correlation between postoperative LDI subgroups of normolordotic, hypo- or hyperlordotic patients and the clinical outcome of posterolateral fusion and TLIF surgery. A trend towards lower rate of revision surgery in the normolordotic group compared to the hypo- and hyperlordotic group was observed.

Intraoperative Irrigation and Risk of Chronic Subdural Hematoma Recurrence.

BACKGROUND AND OBJECTIVES: In most neurosurgical centers, irrigation is an essential part of the surgical procedure for chronic subdural hematoma (CSDH). However, it is unknown whether the volume of irrigation fluid affects the risk of CSDH recurrence. This study aimed to investigate a potential association between the volume of irrigation fluid used during burr hole evacuation of CSDH and the risk of CSDH recurrence. METHODS: This study is a subanalysis of 2 randomized trials (Drain Time & Drain Time 2) designed to investigate the effect of drainage duration on the recurrence of CSDH. Intraoperative irrigation volume was measured, and patients were followed for 90 days for recurrent CSDH. RESULTS: A total of 525 patients with CSDH were included. There was no significant difference in the volume of irrigation fluid used between patients with recurrence (mean = 938 mL, SD = ±552) and without recurrence (mean = 852 mL, SD = ±454) ( P -value = .15). Patients with recurrent CSDH had larger primary CSDH volumes (mean = 134 cm 3 , SD = ±69) than patients without recurrence (mean = 119 cm 3 , SD = ±58) ( P = .04). Multiple logistic regression analysis revealed no association between irrigation volume and recurrence, also when stratified for hematoma size. CONCLUSION: There was no significant association between irrigation volume and recurrent CSDH within 90 days in patients undergoing burr hole surgery for CSDH.

Christmas article: The effect of acetylsalicylic acid and sildenafil on the aesthetic lifespan of spruce branches: a triple-blind, tree branch, randomized, controlled trial.

Introduction Acetylsalicylic acid (ASA) has commonly been touted for its potential to extend the aesthetic lifespan (EL) of Christmas trees when added to the water in the tree stand. This study examined the efficacy of ASA in prolonging the aesthetic longevity of spruce branches, in comparison to placebo and sildenafil. Intervention We conducted a triple-blinded, randomised clinical trial, wherein 60 spruce branches were allocated to one of three treatment arms in a 1:1:1 ratio. The primary intervention was ASA, compared against both placebo and sildenafil treatments. The study's primary endpoint was the EL of the spruce branches. Results All participating branches completed the study. No statistically significant differences were observed in the survival times across the three groups: ASA 17 days (standard deviation (SD): 6), placebo 20 days (SD: 8), and sildenafil 21 days (SD: 7); p = 0.30. Both the log-rank test and adjusted Cox proportional-hazards analyses failed to show any significant variations in aesthetic survival time among the treatment arms (p > 0.05). Conclusion Given our findings, there is no empirical support for the widely held recommendation of adding ASA to the water at the base of a Christmas tree to extend its aesthetic lifespan. Funding none. Trial registration none.

Focused ultrasound for the treatment of brain tumors.

This review investigates focused ultrasound for treating neuro-oncological diseases as an emerging treatment modality. The technique is based on focused ultrasound waves guided by MRI. By using high or low-frequency waves, thermoablation of smaller tissue volumes centrally in the brain or a safe, temporary opening of the blood-brain barrier can be carried out for better penetration of chemotherapy. Numerous studies on neuro-oncological treatments are ongoing, signaling increasing popularity for the technique in the near future.

Acute kidney injury following major emergency abdominal surgery - a retrospective cohort study based on medical records data.

BACKGROUND: Acute Kidney Injury (AKI) is a frequent and serious postoperative complication in trauma or critically ill patients in the intensive care unit. We aimed to estimate the risk of AKI following major emergency abdominal surgery and the association between AKI and 90-day postoperative mortality. METHODS: In this retrospective cohort study, we included patients undergoing major emergency abdominal surgery at the Department of Surgery, Zealand University Hospital, Denmark, from 2010 to 2016. The primary outcome was the occurrence of AKI within postoperative day seven (POD7). AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO)-criteria. The risk of AKI was analysed with a multivariable logistic regression. The association between AKI and 90-day mortality was analysed with a multivariable survival analysis. RESULTS: In the cohort, 122 out of 703 (17.4%) surgical patients had AKI within POD7. Of these, 82 (67.2%) had AKI stage 1, 26 (21.3%) had AKI stage 2, and 14 (11.5%) had AKI stage 3. Fifty-eight percent of the patients who developed postoperative AKI did so within the first 24 h of surgery. Ninety-day mortality was significantly higher in patients with AKI compared with patients without AKI (41/122 (33.6%) versus 40/581 (6.9%), adjusted hazard ratio 4.45 (95% confidence interval 2.69-7.39, P < 0.0001)), and rose with increasing KDIGO stage. Pre-existing hypertension and intraoperative peritoneal contamination were independently associated with the risk of AKI. CONCLUSIONS: The risk of AKI is high after major emergency abdominal surgery and is independently associated with the risk of death within 90 days of surgery.

Blood transfusion in major emergency abdominal surgery.

BACKGROUND: Major emergency abdominal surgery is associated with excess mortality. Transfusion is known to be associated with increased morbidity and emergency surgery is an independent risk factor for perioperative transfusion. The primary objectives of this study were to identify risk factors for transfusion, and secondarily to investigate the influence of transfusion on clinical outcomes after major emergency abdominal surgery. STUDY DESIGN AND METHODS: This study combined retrospective observational data including intraoperative, postoperative, and transfusion data in patients undergoing major emergency abdominal surgery from January 2010 to October 2016 at a Danish university hospital. The primary outcome was a transfusion of any kind from initiation of surgery to postoperative day 7. Secondary outcomes included 7-, 30-, 90-day and long-term mortality (median follow-up = 34.6 months, IQR = 13.0-58.3), lengths of stay, and surgical complication rate (Clavien-Dindo score ≥ 3a). RESULTS: A total of 1288 patients were included and 391 (30%) received a transfusion of any kind. Multivariate logistic regression identified age, hepatic comorbidity, cardiac comorbidity, post-surgical anemia, ADP-receptor inhibitors, acetylsalicylic acid, anticoagulants, and operation type as risk factors for postoperative transfusion. 60.1% of the transfused patients experienced a serious surgical complication within 30 days of surgery compared with 28.1% of the non-transfused patients (p < 0.001). Among patients receiving a postoperative transfusion, unadjusted long-term mortality was increased with a hazard ratio of 3.8 (95% CI 2.9-5.0), p < 0.01. Transfused patients had significantly higher mortality at 7-, 30-, 90- and long-term, as well as a longer hospital stay but in the multivariate analyses, transfusion was not associated with mortality. CONCLUSION: Peri- and postoperative transfusion in relation to major emergency abdominal surgery was associated with an increased risk of postoperative complications. The potential benefits and harms of blood transfusion and clinical significance of pre- and postoperative anemia after major emergency abdominal surgery should be further studied in clinical prospective studies.

Rab2 drives axonal transport of dense core vesicles and lysosomal organelles.

Fast axonal transport of neuropeptide-containing dense core vesicles (DCVs), endolysosomal organelles, and presynaptic components is critical for maintaining neuronal functionality. How the transport of DCVs is orchestrated remains an important unresolved question. The small GTPase Rab2 mediates DCV biogenesis and endosome-lysosome fusion. Here, we use Drosophila to demonstrate that Rab2 also plays a critical role in bidirectional axonal transport of DCVs, endosomes, and lysosomal organelles, most likely by controlling molecular motors. We further show that the lysosomal motility factor Arl8 is required as well for axonal transport of DCVs, but unlike Rab2, it is also critical for DCV exit from cell bodies into axons. We also provide evidence that the upstream regulators of Rab2 and Arl8, Ema and BORC, activate these GTPases during DCV transport. Our results uncover the mechanisms underlying axonal transport of DCVs and reveal surprising parallels between the regulation of DCV and lysosomal motility.

The effects of early enteral nutrition on mortality after major emergency abdominal surgery: A systematic review and meta-analysis with Trial Sequential Analysis.

BACKGROUND: Early oral or enteral nutrition (EEN) has been proven safe, tolerable, and beneficial in elective surgery. In emergency abdominal surgery no consensus exists regarding postoperative nutrition standard regimens. This review aimed to assess the safety and clinical outcomes of EEN compared to standard care after emergency abdominal surgery. METHODS: The review protocol was performed according to the Cochrane Handbook and reported according to PRISMA. Clinical outcomes included mortality, specific complication rates, length of stay, and serious adverse events. Risk of bias was assessed by Cochrane risk of bias tool and Downs and Black. GRADE assessment of each outcome was performed, and Trial Sequential Analysis was completed to obtain the Required Information Size (RIS) of each outcome. RESULTS: From a total of 4741 records screened, a total of five randomized controlled trials and two non-randomized controlled trials were included covering 1309 patients. The included studies reported no safety issues regarding the use of EEN. A significant reduction in the mortality rate of EEN compared with standard care was seen (OR 0.59 (CI 95% 0.34-1.00), I2 = 0%). Meta-analyses on sepsis and postoperative pulmonary complications showed non-significant tendencies in favor of EEN compared with standard care. GRADE assessment of all outcomes was evaluated 'low' or 'very low'. Trial Sequential Analysis revealed that all outcomes had insufficient RIS to confirm the effects of EEN. CONCLUSION: EEN after major emergency surgery is correlated with reduced mortality, however, more high-quality data regarding the optimal timing and composition of nutrition are needed before final conclusions regarding the effects of EEN can be made.

Respiratory function following major emergency abdominal surgery.

The purpose of this study was to evaluate the timewise postoperative respiratory function measured by spirometry and peak flow during the first postoperative week after major emergency abdominal surgery. Patients were tested daily with forced expiratory volume (FEV) and peak flow (PEF) from postoperative day (POD) 1 through to POD7. FEV1, FEV6, FEV1/FEV6 ratio and PEF were analysed by unadjusted linear regression with 95% confidence interval (CI) on mean values for each postoperative day. A total of 35 consecutive patients were included in the study. The FEV at 1 second was 51% of predicted at POD1, which increased to 67% at POD7 (p = 0.005), whereas FEV6 was 55% of predicted at POD1, which increased to 70% at POD7 (p = .008). Respiratory function was not significantly correlated to synchronous pain scores. In conclusion, respiratory function following major emergency abdominal surgery was reduced throughout the first postoperative week irrespective of pain scores.

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery.

BACKGROUND: In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis. METHODS: Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control. RESULTS: In total, 1179 patients who underwent major emergency abdominal surgery during 2010-2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11-2.16, P = 0.009). CONCLUSION: In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

Blondes do not have more fun: a non-blinded crossover field study.

OBJECTIVES: To evaluate whether blondes have more fun, as proposed by Sir Roderick David Stewart in 1978. DESIGN: Prospective, non-randomised crossover field study, 1-2 June 2018. SETTING: Single centre medical writing course, during a break in the course program. PARTICIPANTS: Convenience sample of 21 healthy Danish researchers: ten blondes, nine non-blondes, and two with missing data (bald). INTERVENTION: Participants completed a visual analogue scale (VAS) for fun and Profile of Mood States - Adolescents (POMS-A) questionnaires before and after two rides each on a waterslide (once sitting upright, once lying down). There was a wash-out between rides. MAIN OUTCOME MEASURES: Fun, as assessed by VAS completed moments after completing each waterslide ride. RESULTS: Blondes did not have more fun than non-blondes, neither while sitting upright (median VAS, 60 [IQR, 23-66] v 25 [IQR, 4.5-57]; P = 0.39) nor lying down (median VAS, 70 [IQR, 60-85] v 66 [IQR, 35-80]; P = 0.62). Riding the waterslide lying down was significantly faster (median duration, 9 s; range, 8-13 s) than sitting upright (median duration, 13.6 s; range, 8-37 s; P < 0.001), and also more fun (median VAS, 72 [IQR, 59-85] v 41 [IQR, 14-66]; P = 0.002). CONCLUSIONS: Our findings are not consistent with the statement by Sir Roderick David Stewart that "blondes have more fun"; we found no evidence that blondes experience more fun or are more susceptible to mood changes than non-blondes.

Perioperative Use of Nonsteroidal Anti-inflammatory Drugs Decreases the Risk of Recurrence of Cancer After Colorectal Resection: A Cohort Study Based on Prospective Data.

BACKGROUND: Perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) is known to reduce inflammatory response in relation to surgery. Inflammation may promote recurrence of cancer, thus inhibition by use of NSAIDs could reduce recurrence after surgery. OBJECTIVE: The aim of this study was to examine the association between perioperative use of NSAIDs and cancer recurrence, as well as disease-free survival (DFS) and mortality after colorectal cancer surgery. METHODS: This was a cohort study based on data from a prospective clinical database, electronic medical records, and nationwide registers, and included patients from six major colorectal centers in Denmark. The primary outcome was cancer recurrence, while secondary outcomes included 5-year mortality and DFS. RESULTS: Overall, 2308 patients undergoing colorectal cancer surgery between 1 January 2006 and 31 December 2009 were included. A total of 909 patients received at least 2 days of treatment with NSAIDs, of whom 702 (77.2%) received ibuprofen and 204 (22.4%) received diclofenac. Cox regression analysis adjusting for NSAIDs resulted in decreased recurrence risk (adjusted hazard ratio [HRadjusted] 0.84, 95% confidence interval [CI] 0.72-0.99; p = 0.042). Competing risk analysis confirmed the finding, with an HRadjusted of 0.76 (95% CI 0.60-0.97; p = 0.026). There was no significant effect on mortality or DFS. Sensitivity analysis of the effect of ibuprofen reported an HRadjusted of 0.83 (95% CI 0.70-1.00; p = 0.047). In restricted analyses of localized disease only (Union for International Cancer Control [UICC] I-II) and elective surgery only, no effect was found (localized: HRadjusted 0.81, 95% CI 0.62-1.06, p = 0.12; elective: HRadjusted 0.85, 95% CI 0.72-1.01, p = 0.063). CONCLUSIONS: Perioperative use of NSAIDs was associated with a reduced risk of cancer recurrence after resection for colorectal cancer. No effect on 5-year mortality or DFS was found.

The Effect of Perioperative Iron Therapy in Acute Major Non-cardiac Surgery on Allogenic Blood Transfusion and Postoperative Haemoglobin Levels: A Systematic Review and Meta-analysis.

BACKGROUND: Perioperative anaemia in relation to surgery is associated with adverse clinical outcomes. In an elective surgical setting, it is possible to optimize patients prior to surgery, often by iron supplementation with correction of anaemia. Possibilities for optimization prior to and during acute surgical procedures are limited. This review investigates whether iron treatment initiated perioperatively improves outcomes in patients undergoing major acute non-cardiac surgery. METHOD: This systematic review was performed using PubMed, EMBASE (Ovid) and Scopus to identify current evidence on iron supplementation in acute surgery. Primary outcomes were allogenic blood transfusion (ABT) rate and changes in haemoglobin. Secondary outcomes were postoperative mortality, length of stay (LOS), and postoperative complications. Iron was administered at latest within 24 h after end of surgery. RESULTS: Of the 5413 studies screened, four randomized controlled trials and nine observational cohort studies were included. Ten studies included patients with hip fractures. A meta-analysis of seven studies showed a risk reduction of transfusion (OR = 0.35 CI 95% (0.20-0.63), p = 0.0004, I2 = 66%). No influence on plasma haemoglobin was found. Postoperative mortality was reduced in the iron therapy group in a meta-analysis of four observational studies (OR 0.50 (CI 95% 0.26-0.96) p = 0.04). No effect was found on LOS, but a reduction in postoperative infection was seen in four studies. CONCLUSIONS: This review examined perioperative iron therapy in acute major non-cardiac surgery. IV iron showed a lower 30-day mortality, a reduction in postoperative infections and a reduction in ABT largely due to the observational studies. The review primarily consisted of small observational studies and does not have the power to formally recommend this practice.

The impact of blood type on transfusion after major emergency abdominal surgery.

BACKGROUND: ABO dependent variation in von Willebrand factor (vWF) and factor VIII have an impact on hemostasis. Several contradictory studies have investigated the influence of ABO blood type in surgical hemorrhage. Emergency surgery is associated with an increased risk of perioperative hemorrhage leading to inferior clinical outcomes. The aim of this study was to investigate if patients with blood type O received more transfusions with blood components compared with non-O patients after major emergency abdominal surgery. STUDY DESIGN AND METHODS: This retrospective observational study combined perioperative data including hemoglobin with transfusion data in patients undergoing emergency surgery at a university hospital between January 2010 and October 2016. The primary outcome was postoperative transfusion stratified into early transfusion, within 24 hours after surgery, and late transfusion from 24 hours to 7 days (POD7) after surgery. RESULTS: A total of 869 patients were included, 363 patients with blood type O (42.0%) and 501 (58.0%) with blood type non-O. We found no difference in the need for transfusion with 42 (11.6%) patients with blood type O and 66 (13.2%) patients with blood type non-O receiving early transfusion and 39 (13.4%) and 48 (11.9%) of O and non-O patients, respectively, receiving late transfusion. Multivariate logistic regression analysis showed an adjusted OR of 0.915 (95% CI 0.569-1.471) for early transfusion and an adjusted OR of 1.307 (95% CI 0.788-2.169) for late transfusion in patients with blood type O. Likewise, no difference was seen with respect to the change in hemoglobin levels before and after surgery as well as transfused volume. CONCLUSION: We did not find an association between transfusion or perioperative changes in hemoglobin with respect to blood type ABO.