High prevalence of dysfunctional uterine bleeding in candidates for metabolic/bariatric surgery: increased endometrial cancer risk?

BACKGROUND: Endometrial cancer (EC) is the strongest obesity-associated malignancy and the fastest-growing cancer in young women. Early identification of EC and other endometrial pathology (malignant and nonmalignant) in women with severe obesity may improve treatment options and uterine preservation. Screening for endometrial pathology using abnormal or postmenopausal uterine bleeding (APUB) as a surrogate in women pursuing metabolic/bariatric surgery may be clinically beneficial, but data supporting this effort are limited. OBJECTIVE: To develop and institute a screening program for APUB as a surrogate for endometrial pathology in bariatric surgery candidates. SETTING: Two, academic metabolic/bariatric surgery programs in Louisiana, United States. METHODS: The Modified SAMANTA is a 10-item questionnaire that was implemented to identify patients with APUB, specifically combining tools designed to identify anovulatory/postmenopausal and heavy menstrual bleeding. Demographic (age, race), body mass index, and questionnaire data were analyzed with respect to positive screening using data from March 2021 through May 2023. RESULTS: Of 1371 eligible women presenting for surgical evaluation, 664 (48.4%) positive screens were identified and referred for gynecologic evaluation to rule out endometrial hyperplasia/cancer or other endometrial pathology. The likelihood of positive screening for APUB was associated with increasing BMI (P = .001) and Black/African American race (P = .003), as well as increasing SAMANTA score (P < .001). In contrast, risk of positive screening was negatively associated with increasing age (P < .001). CONCLUSIONS: Women presenting for metabolic/bariatric surgery have a high prevalence of APUB and, given this dysfunctional bleeding and concurrent obesity, are at greater risk for underlying EC. Potential risk factors for APUB, given their associations with screening positive, include increased body mass index, younger age, and Black/African American race. Standardized screening with appropriate gynecologic referral should be a routine part of the overall evaluation for women with severe obesity.

The Role of Preoperative Abdominal Ultrasound in the Preparation of Patients Undergoing Primary Metabolic and Bariatric Surgery: A Machine Learning Algorithm on 4418 Patients' Records.

BACKGROUND: The utility of preoperative abdominal ultrasonography (US) in evaluating patients with obesity before metabolic bariatric surgery (MBS) remains ambiguously defined. METHOD: Retrospective analysis whereby patients were classified into four groups based on ultrasound results. Group 1 had normal findings. Group 2 had non-significant findings that did not affect the planned procedure. Group 3 required additional or follow-up surgeries without changing the surgical plan. Group 4, impacting the procedure, needed further investigations and was subdivided into 4A, delaying surgery for more assessments, and 4B, altering or canceling the procedure due to critical findings. Machine learning techniques were utilized to identify variables. RESULTS: Four thousand four hundred eighteen patients' records were analyzed. Group 1 was 45.7%. Group 2, 35.7%; Group 3, 17.0%; Group 4, 1.5%, Group 4A, 0.8%; and Group 4B, 0.7%, where surgeries were either canceled (0.3%) or postponed (0.4%). The hyperparameter tuning process identified a Decision Tree classifier with a maximum tree depth of 7 as the most effective model. The model demonstrated high effectiveness in identifying patients who would benefit from preoperative ultrasound before MBS, with training and testing accuracies of 0.983 and 0.985. It also showed high precision (0.954), recall (0.962), F1 score (0.958), and an AUC of 0.976. CONCLUSION: Our study found that preoperative ultrasound demonstrated clinical utility for a subset of patients undergoing metabolic bariatric surgery. Specifically, 15.9% of the cohort benefited from the identification of chronic calculous cholecystitis, leading to concomitant cholecystectomy. Additionally, surgery was postponed in 1.4% of the cases due to other findings. While these findings indicate a potential benefit in certain cases, further research, including a cost-benefit analysis, is necessary to fully evaluate routine preoperative ultrasound's overall utility and economic impact in this patient population.

Importance of optical coherence tomography before cataract surgery.

PURPOSE: To determine the importance of optical coherence tomography (OCT) in patients scheduled for cataract surgery who present with no pathologies in biomicroscopic fundus examination. DESIGN: Retrospective study. METHODS: In this study, the routine ophthalmologic examination of patients who were recommended cataract surgery was performed.Occult retinal pathologies were evaluated using OCT in patients without any pathologies in biomicroscopic fundus examination.According to whether retinal pathologies were detected on OCT, the patients were divided into two groups: normal and abnormal OCT.The findings of patients with retinal pathologies on OCT and their distribution according to age were also evaluated. RESULTS: A total of 271 eyes from 271 patients were evaluated.The number of patients with retinal pathologies on OCT despite normal fundoscopic examination findings was 38(14.0%).Of these patients,15(39.4%) had an epiretinal membrane,10(26.3%) had age-related macular degeneration, eight(21%) had vitreomacular traction, two(5.2%) had a lamellar hole, and 1(2.6%) patient each had a full-thickness macular hole, an intraretinal cyst, and photoreceptor layer damage.The age distribution of the patients with retinal pathologies was as follows: two patients,<60 years; six patients,60-70 years;14 patients,70-80 years; and 16 patients,>80 years.The rate of patients aged > 70 years and above was 78.9%.There was no statistically significant difference between the normal and abnormal OCT groups in terms of age, gender, the presence of systemic diseases, visual acuity, central macular thickness, and cataract type or density(p > 0.05 for all). CONCLUSION: In one of seven patients evaluated, retinal pathologies were detected on OCT despite normal fundoscopic examination findings.OCT can be used to detect occult retinal pathologies that cannot be detected by biomicroscopic fundus examination before cataract surgery.

Value-based preoperative assessment in a large academic hospital.

BACKGROUND: Value-based healthcare (VBHC) is an approach that focuses on delivering the highest possible value for patients while driving cost efficiency in health services. It emphasizes improving patient outcomes and experiences while optimizing the use of resources, shifting the healthcare system's focus from the volume of services to the value delivered. Our study assessed the effectiveness of implementing a VBHC-principled, tailored preoperative evaluation in enhancing patient care and outcomes, as well as reducing healthcare costs. METHODS: We employed a quality improvement, before-and-after approach to assessing the effects of implementing VBHC strategies on the restructuring of the preoperative evaluation clinics at Humanitas Research Hospital. The intervention introduced a VBHC-tailored risk matrix during the postintervention phase (year 2021), and the results were compared with those of the preintervention phase (2019). The primary study outcome was the difference in the number of preoperative tests and visits at baseline and after the VBHC approach. Secondary outcomes were patient outcomes and costs. RESULTS: A total of 9722 patients were included: 5242 during 2019 (baseline) and 4,480 during 2021 (VBHC approach). The median age of the population was 63 (IQR 51-72), 23% of patients were classified as ASA 3 and 4, and 26.8% (2,955 cases) were day surgery cases. We found a considerable decrease in the number of preoperative tests ordered for each patient [6.2 (2.5) vs 5.3 (2.6) tests, p < 0.001]. The number of preoperative chest X-ray, electrocardiogram, and cardiac exams decreased significantly with VBHC. The length of the preoperative evaluation was significantly shorter with VBHC [373 (136) vs 290 (157) min, p < 0.001]. Cost analysis demonstrated a significant reduction in costs, while there was no difference in clinical outcomes. CONCLUSIONS: We demonstrated the feasibility, safety, and cost-effectiveness of a tailored approach for preoperative evaluation. The implementation of VBHC enhanced value, as evidenced by decreased patient time in preoperative evaluation and by a reduction in unnecessary preoperative tests.

Impact of preanaesthetic electrocardiogram on decision making and modification of anaesthetic protocols in dogs.

BACKGROUND: This retrospective observational study explored the impact of preanaesthetic electrocardiogram (ECG) assessment on preoperative echocardiography requests and modifications to a standardised anaesthetic protocol in healthy dogs. METHODS: A total of 228 healthy dogs with no previously diagnosed heart disease that underwent general anaesthesia at Complutense Veterinary Teaching Hospital from December 2017 to June 2018 were included. Preanaesthetic ECGs were assessed for abnormalities, and the findings were documented. The number of dogs requiring echocardiography, based on ECG findings, and the echocardiography results were recorded. All anaesthesia-related decisions were documented. RESULTS: Overall, 72 dogs (31.6%) exhibited ECG abnormalities. Echocardiography was requested for five dogs (2.2%). The anaesthetic protocol was changed in 11 dogs (15.3% of those with ECG abnormalities). P wave disturbances, ventricular premature complexes and impulse conduction issues were abnormalities that prompted echocardiography. Bradycardia and electrical impulse conduction abnormalities influenced protocol modifications. LIMITATIONS: The limited sample size meant that it was not possible to investigate potential correlations between demographics and ECG alterations. CONCLUSIONS: Preanaesthetic ECG screening was useful for promoting echocardiography and influencing anaesthesia plans in a subset of dogs. Despite this, further assessment of the impact of routine use of non-targeted preoperative ECG on anaesthesia-related outcomes is warranted.

Surgeon variability in repair of hiatal hernia at the time of bariatric surgery.

BACKGROUND: Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system. METHODS: A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed. RESULTS: From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001). CONCLUSION: Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

MULTIDIMENSIONAL PREOPERATIVE EVALUATION AND ITS ROLE IN PREVENTING PERIOPERATIVE COMPLICATIONS IN ELDERLY INDIVIDUALS WITH FRACTURES / AVALIAÇÃO PRÉ-OPERATÓRIA MULTIDIMENSIONAL E SEU PAPEL NA PREVENÇÃO DE COMPLICAÇÕES PERIOPERATÓRIAS EM IDOSOS COM FRATURAS

Introduction: Elderly patients have higher rates of morbidity and mortality during hospitalizations, diagnostic and surgical procedures. In order to improve the quality of care for the elderly, the APOIO (Preoperative Assessment of Elderly and Care Guidance) protocol was created, a tool to measure the risks of surgical complications. Objective: To evaluate the impact of APOIO on several outcomes, in order to validate it as a useful vehicle in the prevention of perioperative complications in elderly patients with fractures. Method: Retrospective cross-sectional study through review of 218 medical records of elderly patients hospitalized for fractures, and with surgical indication, having collected data on sex, age, reason for hospitalization, type of fracture, indication or not of surgical treatment, evaluation or not by APOIO, indication or not of ICU in the postoperative period, length of ICU stay, total length of hospitalization, immediate outcome and outcome within 30 days after the operation. Result: It was found that the application of APOIO was associated with a 70% reduction in the chances of death during hospitalization (p=0.040), length of stay in the ICU (p<0.001) and total length of hospital stay (p = 0.010). There was also a trend towards a reduction in the death rate within 30 days of the postoperative period (p = 0.117). Conclusion: The application of the APOIO tool reduces the length of hospitalization, optimizes indication and length of stay in the ICU and, also, reduces the risk of death in elderly people undergoing surgical treatment for fractures.

Introdução: Pacientes idosos apresentam maior morbidade e mortalidade em internamentos hospitalares, procedimentos diagnósticos e cirúrgicos. Buscando melhorar a qualidade assistencial aos idosos foi criado o protocolo APOIO (Avaliação Pré-Operatória de Idosos e Orientação de cuidados), ferramenta para mensurar os riscos de complicações cirúrgicas. Objetivo: Avaliar o impacto do APOIO sobre vários desfechos, a fim de validá-lo como veículo útil na prevenção de complicações perioperatórias em idosos com fraturas. Método: Pesquisa retrospectiva transversal por meio de revisão de 218 prontuários de pacientes idosos internados por fraturas, e com indicação cirúrgica, tendo sido coletados dados sobre sexo, idade, motivo do internamento, tipo de fratura, indicação ou não de tratamento cirúrgico, avaliação ou não pela APOIO, indicação ou não de UTI no pós-operatório, duração do internamento em UTI, duração total do internamento, desfecho imediato e desfecho em 30 dias após a operação. Resultado: Foi constatado que a aplicação do APOIO foi associada à redução de 70% nas chances de óbito durante o internamento (p = 0,040), ao tempo de permanência em UTI (p <0,001) e ao tempo total de internamento hospitalar (p =  0,010). Observou-se ainda tendência à redução na taxa de óbitos em 30 dias do pós-operatório (p = 0,117). Conclusão: A aplicação da ferramenta APOIO reduz tempo de internamento, otimiza indicação e tempo de permanência em UTI e ainda diminui o risco de óbito de idosos submetidos a tratamentos cirúrgicos de fraturas.

Implementation of a software-based decision support tool for guideline-appropriate preoperative evaluation: a prospective agreement study.

BACKGROUND: Guideline adherence in the medical field leaves room for improvement. Digitalised decision support helps improve compliance. However, the complex nature of the guidelines makes implementation in clinical practice difficult. METHODS: This single-centre prospective study included 204 adult ASA physical status 3-4 patients undergoing elective noncardiac surgery at a German university hospital. Agreement of clearance for surgery between a guideline expert and a digital guideline support tool was investigated. The decision made by the on-duty anaesthetists (standard approach) was assessed for agreement with the expert in a cross-over design. The main outcome was the level of agreement between digital guideline support and the expert. RESULTS: The digital guideline support approach cleared 18.1% of the patients for surgery, the standard approach cleared 74.0%, and the expert approach cleared 47.5%. Agreement of the expert decision with digital guideline support (66.7%) and the standard approach (67.6%) was fair (Cohen's kappa 0.37 [interquartile range 0.26-0.48] vs 0.31 [0.21-0.42], P=0.6). Taking the expert decision as a benchmark, correct clearance using digital guideline support was 50.5%, and correct clearance using the standard approach was 44.6%. Digital guideline support incorrectly asked for additional examinations in 31.4% of the patients, whereas the standard approach did not consider conditions that would have justified additional examinations before surgery in 29.4%. CONCLUSIONS: Strict guideline adherence for clearance for surgery through digitalised decision support inadequately considered patients, clinical context. Vague formulations, weak recommendations, and low-quality evidence complicate guideline translation into explicit rules. CLINICAL TRIAL REGISTRATION: NCT04058769.

Preoperative Anesthesia Virtual Video Consultations in a Preadmission Clinic: Quality Improvement Study.

BACKGROUND: The preadmission clinic (PAC) is crucial in perioperative care, offering evaluations, education, and patient optimization before surgical procedures. During the COVID-19 pandemic, the PAC adapted by implementing telephone visits due to a lack of infrastructure for video consultations. While the pandemic significantly increased the use of virtual care, including video appointments as an alternative to in-person consultations, our PAC had not used video consultations for preoperative assessments. OBJECTIVE: This study aimed to develop, implement, and integrate preoperative video consultations into the PAC workflow. METHODS: A prospective quality improvement project was undertaken using the Plan-Do-Study-Act (PDSA) methodology. The project focused on developing, implementing, and integrating virtual video consultations at London Health Sciences Centre and St. Joseph Health Care (London, Ontario, Canada) in the PAC. Data were systematically collected to monitor the number of patients undergoing video consultations, address patient flow concerns, and increase the percentage of video consultations. Communication between the PAC, surgeon offices, and patients was analyzed for continuous improvement. Technological challenges were addressed, and procedures were streamlined to facilitate video calls on appointment days. RESULTS: The PAC team, which includes professionals from medicine, anesthesia, nursing, pharmacy, occupational therapy, and physiotherapy, offers preoperative evaluation and education to surgical patients, conducting approximately 8000 consultations annually across 3 hospital locations. Following the initial PDSA cycles, the interventions consistently improved the video consultation utilization rate to 17%, indicating positive progress. With the onset of PDSA cycle 3, there was a notable surge to a 29% utilization rate in the early phase. This upward trend continued, culminating in a 38% utilization rate of virtual video consultations in the later stages of the cycle. This heightened level was consistently maintained throughout 2023, highlighting the sustained success of our interventions. CONCLUSIONS: The quality improvement process significantly enhanced the institution's preoperative video consultation workflow. By understanding the complexities within the PAC, strategic interventions were made to integrate video consultations without compromising efficiency, morale, or safety. This project highlights the potential for transformative improvements in health care delivery through the thoughtful integration of virtual care technologies.

Preoperative evaluation profile of patients undergoing arterial vascular surgery in a tertiary hospital.

BACKGROUND: Patients with peripheral arterial disease have an increased risk of developing cardiovascular complications in the postoperative period of arterial surgeries known as Major Adverse Cardiac Events (MACE), which includes acute myocardial infarction, heart failure, malignant arrhythmias, and stroke. The preoperative evaluation aims to reduce mortality and the risk of MACE. However, there is no standardized approach to performing them. The aim of this study was to compare the preoperative evaluation conducted by general practitioners with those performed by cardiologists. METHODS: This is a retrospective analysis of medical records of patients who underwent elective arterial surgeries from January 2016 to December 2020 at a tertiary hospital in São Paulo, Brazil. The authors compared the preoperative evaluation of these patients according to the initial evaluator (general practitioners vs. cardiologists), assessing patients' clinical factors, mortality, postoperative MACE incidence, rate of requested non-invasive stratification tests, length of hospital stay, among others. RESULTS: 281 patients were evaluated: 169 assessed by cardiologists and 112 by general practitioners. Cardiologists requested more non-invasive stratification tests (40.8%) compared to general practitioners (9%) (p < 0.001), with no impact on mortality (8.8% versus 10.7%; p = 0.609) and postoperative MACE incidence (10.6% versus 6.2%; p = 0.209). The total length of hospital stay was longer in the cardiologist group (17.27 versus 11.79 days; p < 0.001). CONCLUSION: The increased request for exams didn't have a significant impact on mortality and postoperative MACE incidence, but prolonged the total length of hospital stay. Health managers should consider these findings and ensure appropriate utilization of human and financial resources.

Machine Learning Model for Anesthetic Risk Stratification for Gynecologic and Obstetric Patients: Cross-Sectional Study Outlining a Novel Approach for Early Detection.

BACKGROUND: Preoperative evaluation is important, and this study explored the application of machine learning methods for anesthetic risk classification and the evaluation of the contributions of various factors. To minimize the effects of confounding variables during model training, we used a homogenous group with similar physiological states and ages undergoing similar pelvic organ-related procedures not involving malignancies. OBJECTIVE: Data on women of reproductive age (age 20-50 years) who underwent gestational or gynecological surgery between January 1, 2017, and December 31, 2021, were obtained from the National Taiwan University Hospital Integrated Medical Database. METHODS: We first performed an exploratory analysis and selected key features. We then performed data preprocessing to acquire relevant features related to preoperative examination. To further enhance predictive performance, we used the log-likelihood ratio algorithm to generate comorbidity patterns. Finally, we input the processed features into the light gradient boosting machine (LightGBM) model for training and subsequent prediction. RESULTS: A total of 10,892 patients were included. Within this data set, 9893 patients were classified as having low anesthetic risk (American Society of Anesthesiologists physical status score of 1-2), and 999 patients were classified as having high anesthetic risk (American Society of Anesthesiologists physical status score of >2). The area under the receiver operating characteristic curve of the proposed model was 0.6831. CONCLUSIONS: By combining comorbidity information and clinical laboratory data, our methodology based on the LightGBM model provides more accurate predictions for anesthetic risk classification. TRIAL REGISTRATION: Research Ethics Committee of the National Taiwan University Hospital 202204010RINB; https://www.ntuh.gov.tw/RECO/Index.action.

Descemet Membrane Endothelial Keratoplasty for Penetrating Keratoplasty.

Background: Descemet membrane endothelial keratoplasty (DMEK) has been utilized more frequently during recent years to treat penetrating keratoplasty (PKP) graft failures. The perioperative evaluation technique of anterior segment optical coherence tomography (AS-OCT) is increasingly significant. Our goal is to discuss DMEK surgical and clinical for subsequent PKP graft failure, along with significant surgical modifications and adjustments in accordance with preoperative assessment utilizing AS-OCT. Materials and Methods: Patients' records who performed DMEK for PKP failure were retrospectively reviewed. Demographic information, PKP graft size determined by postoperative problems, corneal donor endothelial cell density (ECD), AS-OCT, central pachymetry, visual acuity (VA) evaluated in Snellen units, intraoperative surgical procedure modifications, and postoperative ECD were all included in the data collection. Results: The observation was conducted with 16 patients with 16 eyes, nine males and seven females. The observation period is 18 months. DMEK was performed at an average age of 63. Preoperative AS-OCT was performed on all patients, and based on cases, surgical plans were created. Before processing DMEK, the mean VA is 0.04, and central pachymetry is 685 m. They improved considerably to 0.3 (P value = 0.001) and 542 m (P value = 0.008) at the most recent follow-up. About 93.75% of the grafts were adhered to after the procedure. Late decompensation caused a 6.25% graft failure rate. Graft detachment rates and cases requiring rebubble rates were respectively 18.75%. Conclusion: In DMEK for failed PKP, a good case-specific preoperative assessment by AS-OCT is essential. As a result, it relies on developing a surgical strategy that can improve surgical outcomes, lower the risk of complications, and quicken visual recovery.

Comparison of frailty indexes as predictors of clinical outcomes after major thoracic surgery.

Background: Despite greater appreciation for the importance of frailty in surgical patients, due to improved understanding that frailty is often linked to poor outcomes, the optimal method of assessment remains unknown. In this study, we sought to evaluate the prevalence of frailty in patients considered for elective thoracic surgery and to test the ability of several frailty measurements to predict postoperative outcomes. Methods: Patients included were candidates for major elective thoracic surgery. Preoperative assessment of frailty included the Fried frailty phenotype, the Edmonton Frail Scale (EFS), the modified frailty index (mFI), the Clinical Frailty Scale (CFS), and additional components of frailty. Outcome data include days with chest drain, length of hospital stay, and postoperative adverse events. Results: According to the Fried frailty phenotype, 53% of 94 patients included were prefrail or frail. A significant association between frailty and postoperative complications was found (odds ratio 7.65; P=0.001). No association between CFS, mFI, EFS, and complications was observed. The Frailty Phenotype seemed the most accurate in predicting postoperative complications, with an area under the curve (AUC) of 0.77. Twenty-seven percent of patients meet the criteria for depression according to the Geriatric Depression Scale and they showed a higher risk of postoperative complications (OR 2.47; P=0.03). A lower psoas muscle index was associated with a higher risk of complications (OR 3.40; P=0.04). Conclusions: According to our results, the Fried frailty phenotype seems the most accurate tool to test frailty in patients undergoing thoracic resections. Surgeons should be aware that, although these aspects are not routinely tested, they are potential targets to improve clinical outcomes. Studies on additional interventions specifically targeting frail people in the setting of elective thoracic surgery are required.

Excessive Preoperative Testing in Otolaryngology: A Retrospective Comparison of Primary Care and Perioperative Providers.

OBJECTIVE: To assess the association between provider type (primary care provider [PCP] or perioperative provider) and excessive preoperative testing. STUDY DESIGN: Cross-sectional study. SETTING: Academic medical center. METHODS: Electronic medical records of adult patients who obtained an outpatient preoperative assessment and underwent surgery in the Department of Otolaryngology-Head and Neck Surgery during the first 2 weeks of January 2019 (n = 94) were reviewed. Patients receiving preoperative tests beyond those recommended by the guidelines were deemed to have had excessive testing. Descriptive statistics were used to characterize the study population. Simple and multivariate logistic regression were used to analyze the association between the outcome and the predictor variables. RESULTS: Overall, 44.7% of preoperative evaluations had excessive testing. Patients who had their preoperative evaluation performed by a perioperative provider had 89% lower odds of having excessive preoperative testing compared to those evaluated by a PCP (odds ratio = 0.11, 95% confidence interval: [0.03, 0.37], P < .001). Female sex, younger age, and higher risk of major adverse cardiac events were associated with greater odds of excessive testing. CONCLUSION: Excessive preoperative testing is more commonly performed by PCPs compared to perioperative providers. These results give preliminary evidence in support of a potential shift in the clinical responsibility of preoperative evaluation from PCPs to perioperative providers in order to reduce excessive testing and promote high-value health care. The next steps include validating these findings, identifying reasons for differential guideline concordance, and intervening accordingly.

The value of ictal scalp EEG in focal epilepsies surgery: a retrospective analysis.

OBJECTIVE: To describe the association between preoperative ictal scalp electroencephalogram (EEG) results and surgical outcomes in patients with focal epilepsies. METHODS: The data of consecutive patients with focal epilepsies who received surgical treatments at our center from January 2012 to December 2021 were retrospectively analyzed. RESULTS: Our data showed that 44.2% (322/729) of patients had ictal EEG recorded on video EEG monitoring during preoperative evaluation, of which 60.6% (195/322) had a concordant ictal EEG results. No significant difference of surgery outcomes between patients with and without ictal EEG was discovered. Among MRI-negative patients, those with concordant ictal EEG had a significantly better outcome than those without ictal EEG (75.7% vs. 43.8%, p = 0.024). Further logistic regression analysis showed that concordant ictal EEG was an independent predictor for a favorable outcome (OR = 4.430, 95%CI 1.175-16.694, p = 0.028). Among MRI-positive patients, those with extra-temporal lesions and discordant ictal EEG results had a worse outcome compared to those without an ictal EEG result (44.7% vs. 68.8%, p = 0.005). Further logistic regression analysis showed that discordant ictal EEG was an independent predictor of worse outcome (OR = 0.387, 95%CI 0.186-0.807, p = 0.011) in these patients. Furthermore, our data indicated that the number of seizures was not associated with the concordance rates of the ictal EEG, nor the surgical outcomes. CONCLUSIONS: The value of ictal scalp EEG for epilepsy surgery varies widely among patients. A concordant ictal EEG predicts a good surgical outcome in MRI-negative patients, whereas a discordant ictal EEG predicts a poor postoperative outcome in lesional extratemporal lobe epilepsy.

The Application of Next-Generation Sequencing in Preoperative Evaluation for Urologic Stone Surgery.

Introduction: Next-generation sequencing (NGS) is a new molecular technique for identifying microorganisms. Treating bacteriuria in patients undergoing stone removal procedures is important for preventing postoperative urinary tract infection (UTI). The objective of this study is to assess the usefulness of preoperative urine NGS testing by comparing NGS with standard urine culture in predicting postoperative UTI after ureteroscopic lithotripsy (URSL) and percutaneous nephrolithotomy (PCNL). Materials and Methods: This prospective study was conducted from February 16, 2022, to January 11, 2024. Sixty subjects who underwent URSL or PCNL were included. Preoperative voided urine samples were collected for urine culture and tested by MicroGenDX for urine polymerase chain reaction (PCR) and urine NGS. Stone specimens obtained intraoperatively were also sent for stone culture and MicrogenDx. Patients were monitored for 4 weeks post-operation for recording clinical outcomes related to infections and complications. Results: Twenty-six (43.3%) male and 34 (56.7%) female participants were included. Twenty-six (43.3%) patients underwent PCNL (15 standard PCNL and 11 mini PCNL), and 34 (56.7%) underwent URSL. Standard urine culture identified positive results in 26 cases (43.3%), PCR for 17 cases (28.3%), and NGS for 31 cases (51.7%). The overall postoperative UTI rate was 6 (10%). Standard urine culture demonstrated a sensitivity of 50%, specificity of 57.4%, and accuracy of 56.7%. Positive predictive value (PPV) was notably poor at 11.5%. Urine NGS showed a higher sensitivity of 83.3%, specificity of 53.7%, accuracy of 55%, and PPV of 16.7%. Conclusion: Urine NGS significantly improves the sensitivity of detecting microorganisms in preoperative urine compared with standard urine culture. Despite its high sensitivity and capability to identify nonculturable bacteria, using NGS alongside standard urine culture is recommended. This parallel approach harnesses the strengths of both methods. Integrating NGS into standard practice could elevate the quality of care, especially for patients at high risk of UTIs, such as those undergoing invasive stone removal procedures.

Preoperative pain sensitivity and its correlation with postoperative acute and chronic pain: a systematic review and meta-analysis.

BACKGROUND: Preoperative pain sensitivity (PPS) can be associated with postsurgical pain. However, estimates of this association are scarce. Confirming this correlation is essential to identifying patients at high risk for severe postoperative pain and for developing analgesic strategy. This systematic review and meta-analysis summarises PPS and assessed its correlation with postoperative pain. METHODS: PubMed, Scopus, Cochrane Library, and PsycINFO were searched up to October 1, 2023, for studies reporting the association between PPS and postsurgical pain. Two authors abstracted estimates of the effect of each method independently. A random-effects model was used to combine data. Subgroup analyses were performed to investigate the effect of pain types and surgical procedures on outcomes. RESULTS: A total of 70 prospective observational studies were included. A meta-analysis of 50 studies was performed. Postoperative pain was negatively associated with pressure pain threshold (PPT; r=-0.15, 95% confidence interval [CI] -0.23 to -0.07]) and electrical pain threshold (EPT; r=-0.28, 95% CI -0.42 to -0.14), but positively correlated with temporal summation of pain (TSP; r=0.21, 95% CI 0.12-0.30) and Pain Sensitivity Questionnaire (PSQ; r=0.25, 95% CI 0.13-0.37). Subgroup analysis showed that only TSP was associated with acute and chronic postoperative pain, whereas PPT, EPT, and PSQ were only associated with acute pain. A multilevel (three-level) meta-analysis showed that PSQ was not associated with postoperative pain. CONCLUSIONS: Lower PPT and EPT, and higher TSP are associated with acute postoperative pain while only TSP is associated with chronic postoperative pain. Patients with abnormal preoperative pain sensitivity should be identified by clinicians to adopt early interventions for effective analgesia. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023465727).

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

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