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Artificial intelligence (AI) has been extensively researched in medicine, but its practical application remains limited. Meanwhile, there are various disparities in existing AI-enabled clinical studies, which pose a challenge to global health equity. In this study, we conducted an in-depth analysis of the geo-economic distribution of 159 AI-enabled clinical studies, as well as the gender disparities among these studies. We aim to reveal these disparities from a global literature perspective, thus highlighting the need for equitable access to medical AI technologies.
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BACKGROUND: Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. OBJECTIVE: The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. METHODS: Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. RESULTS: GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. CONCLUSIONS: Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.
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Alta del Paciente , Humanos , Alta del Paciente/normas , Registros Electrónicos de Salud/normas , Método Simple Ciego , LenguajeRESUMEN
BACKGROUND: Diabetic retinopathy (DR) and diabetic macular edema (DME) are major causes of visual impairment that challenge global vision health. New strategies are needed to tackle these growing global health problems, and the integration of artificial intelligence (AI) into ophthalmology has the potential to revolutionize DR and DME management to meet these challenges. MAIN TEXT: This review discusses the latest AI-driven methodologies in the context of DR and DME in terms of disease identification, patient-specific disease profiling, and short-term and long-term management. This includes current screening and diagnostic systems and their real-world implementation, lesion detection and analysis, disease progression prediction, and treatment response models. It also highlights the technical advancements that have been made in these areas. Despite these advancements, there are obstacles to the widespread adoption of these technologies in clinical settings, including regulatory and privacy concerns, the need for extensive validation, and integration with existing healthcare systems. We also explore the disparity between the potential of AI models and their actual effectiveness in real-world applications. CONCLUSION: AI has the potential to revolutionize the management of DR and DME, offering more efficient and precise tools for healthcare professionals. However, overcoming challenges in deployment, regulatory compliance, and patient privacy is essential for these technologies to realize their full potential. Future research should aim to bridge the gap between technological innovation and clinical application, ensuring AI tools integrate seamlessly into healthcare workflows to enhance patient outcomes.
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Médicos , Singapur , Humanos , Actitud del Personal de Salud , Procedimientos InnecesariosRESUMEN
BACKGROUND: Intensive care research has predominantly relied on conventional methods like randomized controlled trials. However, the increasing popularity of open-access, free databases in the past decade has opened new avenues for research, offering fresh insights. Leveraging machine learning (ML) techniques enables the analysis of trends in a vast number of studies. OBJECTIVE: This study aims to conduct a comprehensive bibliometric analysis using ML to compare trends and research topics in traditional intensive care unit (ICU) studies and those done with open-access databases (OADs). METHODS: We used ML for the analysis of publications in the Web of Science database in this study. Articles were categorized into "OAD" and "traditional intensive care" (TIC) studies. OAD studies were included in the Medical Information Mart for Intensive Care (MIMIC), eICU Collaborative Research Database (eICU-CRD), Amsterdam University Medical Centers Database (AmsterdamUMCdb), High Time Resolution ICU Dataset (HiRID), and Pediatric Intensive Care database. TIC studies included all other intensive care studies. Uniform manifold approximation and projection was used to visualize the corpus distribution. The BERTopic technique was used to generate 30 topic-unique identification numbers and to categorize topics into 22 topic families. RESULTS: A total of 227,893 records were extracted. After exclusions, 145,426 articles were identified as TIC and 1301 articles as OAD studies. TIC studies experienced exponential growth over the last 2 decades, culminating in a peak of 16,378 articles in 2021, while OAD studies demonstrated a consistent upsurge since 2018. Sepsis, ventilation-related research, and pediatric intensive care were the most frequently discussed topics. TIC studies exhibited broader coverage than OAD studies, suggesting a more extensive research scope. CONCLUSIONS: This study analyzed ICU research, providing valuable insights from a large number of publications. OAD studies complement TIC studies, focusing on predictive modeling, while TIC studies capture essential qualitative information. Integrating both approaches in a complementary manner is the future direction for ICU research. Additionally, natural language processing techniques offer a transformative alternative for literature review and bibliometric analysis.
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Cuidados Críticos , Unidades de Cuidados Intensivos , Niño , Humanos , Centros Médicos Académicos , Bibliometría , Aprendizaje AutomáticoRESUMEN
PURPOSE: Preoperative anemia is associated with poor postoperative outcomes. Older patients have limited physiologic reserves, which renders them vulnerable to the stress of major abdominal surgery. We aimed to determine if the severity of preoperative anemia is associated with early postoperative morbidity among older patients undergoing major abdominal surgery. METHODS: Ethics approval was obtained from SingHealth Centralized Institutional Review Board. This is a prospective observational study conducted in the preoperative anesthesia clinic of a tertiary Singapore hospital from 2017 to 2021. Patient demographic data, comorbidities, and intraoperative details were collected. Outcome measures included blood transfusions, complications according to the Postoperative Morbidity Survey, days alive and out of hospital (DaOH), length of hospital stay, and mortality. RESULTS: A total of 469 patients were analyzed, 37.5% of whom had preoperative anemia (serum hemoglobin of < 13 g·dL-1 in males and < 12 g·dL-1 in females). Anemia was significantly associated with older age, a higher age-adjusted Comprehensive Complication Index score, a higher incidence of diabetes mellitus, and a higher proportion of patients with an American Society of Anesthesiologists Physical Status of III or IV. The severity of anemia was associated with the presence of early postoperative morbidity at day 5, increased blood transfusions, longer length of hospital stay, and fewer DaOH at 30 days and six months. CONCLUSION: Anemia is significantly associated with poorer postoperative outcomes in the older population. The impact of anemia on postoperative outcomes could be further evaluated with quality of life indicators, patient-reported outcome measures, and health economic tools.
RéSUMé: OBJECTIF: L'anémie préopératoire est associée à de mauvais devenirs postopératoires. Les patient·es plus âgé·es ont des réserves physiologiques limitées, ce qui les rend vulnérables au stress d'une chirurgie abdominale majeure. Nous avons cherché à déterminer si la gravité de l'anémie préopératoire était associée à une morbidité postopératoire précoce chez les personnes âgées bénéficiant d'une chirurgie abdominale majeure. MéTHODE: L'approbation éthique a été obtenue auprès du Comité d'examen institutionnel centralisé SingHealth. Il s'agit d'une étude observationnelle prospective menée dans la clinique d'anesthésie préopératoire d'un hôpital tertiaire de Singapour de 2017 à 2021. Les données démographiques des patient·es, les comorbidités et les détails peropératoires ont été recueillis. Les critères d'évaluation comprenaient les transfusions sanguines, les complications selon l'Enquête sur la morbidité postopératoire, le nombre de jours de vie hors de l'hôpital, la durée de séjour à l'hôpital et la mortalité. RéSULTATS: Au total, 469 patient·es ont été analysé·es, dont 37,5% présentaient une anémie préopératoire (hémoglobine sérique < 13 g·dL-1 chez les hommes et < 12 g·dL-1 chez les femmes). L'anémie était significativement associée à un âge plus avancé, à un score plus élevé à l'Indice de complication globale ajusté en fonction de l'âge, à une incidence plus élevée de diabète sucré et à une proportion plus élevée de patient·es de statut physique III ou IV selon l'American Society of Anesthesiologists. La sévérité de l'anémie était associée à la présence d'une morbidité postopératoire précoce au jour 5, à une augmentation des transfusions sanguines, à une durée d'hospitalisation plus longue et à une diminution des jours en vie hors hôpital à 30 jours et six mois. CONCLUSION: L'anémie est significativement associée aux moins bons devenirs postopératoires chez les personnes âgées. L'impact de l'anémie sur les devenirs postopératoires pourrait être évalué plus en détail à l'aide d'indicateurs de qualité de vie, de mesures des issues rapportées par les patient·es et d'outils d'économie de la santé.
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Anemia , Calidad de Vida , Anciano , Femenino , Humanos , Masculino , Anemia/complicaciones , Anemia/epidemiología , Hemoglobinas/análisis , Morbilidad , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Estudios ProspectivosRESUMEN
BACKGROUND: To enhance perioperative outcomes, a perioperative registry that integrates high-quality real-world data throughout the perioperative period is essential. Singapore General Hospital established the Perioperative and Anesthesia Subject Area Registry (PASAR) to unify data from the preoperative, intraoperative, and postoperative stages. This study presents the methodology employed to create this database. METHODS: Since 2016, data from surgical patients have been collected from the hospital electronic medical record systems, de-identified, and stored securely in compliance with privacy and data protection laws. As a representative sample, data from initiation in 2016 to December 2022 were collected. RESULTS: As of December 2022, PASAR data comprise 26 tables, encompassing 153,312 patient admissions and 168,977 operation sessions. For this period, the median age of the patients was 60.0 years, sex distribution was balanced, and the majority were Chinese. Hypertension and cardiovascular comorbidities were also prevalent. Information including operation type and time, intensive care unit (ICU) length of stay, and 30-day and 1-year mortality rates were collected. Emergency surgeries resulted in longer ICU stays, but shorter operation times than elective surgeries. CONCLUSIONS: The PASAR provides a comprehensive and automated approach to gathering high-quality perioperative patient data.
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Anestesia , Data Warehousing , Humanos , Persona de Mediana Edad , Procedimientos Quirúrgicos Electivos , Admisión del Paciente , Sistema de RegistrosRESUMEN
Introduction: Prehabilitation, which involves improving a patient's physical and psychological condition before surgery, has shown potential benefits but has yet to be extensively studied from an economic perspective. To address this gap, a systematic review was conducted to summarize existing economic evaluations of prehabilitation interventions. Methods: The PRISMA Protocols 2015 checklist was followed. Over 16,000 manuscripts were reviewed, and 99 reports on preoperative interventions and screening tests were identified, of which 12 studies were included in this analysis. The costs are expressed in Pounds (GBP, £) and adjusted for inflation to December 2022. Results: The studies were conducted in Western countries, focusing on specific surgical subspecialties. While the interventions and study designs varied, most studies demonstrated cost savings in the intervention group compared to the control group. Additionally, all cost-effectiveness analysis studies favored the intervention group. However, the review also identified several limitations. Many studies had a moderate or high risk of bias, and critical information such as time horizons and discount rates were often missing. Important components like heterogeneity, distributional effects, and uncertainty were frequently lacking as well. The misclassification of economic evaluation types highlighted a lack of knowledge among physicians in prehabilitation research. Conclusion: This review reveals a lack of robust evidence regarding the economics of prehabilitation programs for surgical patients. This suggests a need for further research with rigorous methods and accurate definitions.
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Background: The current Lee's Revised cardiac risk index (RCRI) was created in 1999. Validation studies have found RCRI to be only moderately discriminant. The "Diabetes Mellitus on insulin" component of the score does not accurately reflect the severity of the disease. A previously studied HbA1C:Hemoglobin ratio shows an improved association with outcomes than individual components alone. Study design: A retrospective cohort study was performed in diabetic patients undergoing non-cardiac surgery. Ethics approval was obtained. The study compares the predictive value of RCRI and substitution of the "DM on insulin" component with HH ratio for 30- and 90-day mortality, and postoperative acute myocardial injury (AMI) and acute kidney injury (AKI). Results: A total of 20,099 adult patients were included in the final analysis. The incidence of 30- and 90-day mortality was at 4.2 and 6.5%, respectively. Substitution of HH ratio in RCRI resulted in 687 more patients being in the moderate to high-risk category. The substituted HH-RCRI score had better prediction for 30-day (AUC 0.66 vs. 0.69, p < 0.001) and 90-day mortality (AUC 0.67 vs. 0.70, p < 0.001), and postoperative AMI (AUC 0.69 vs. 0.71, p < 0.001) and AKI (AUC 0.57 vs. 0.62, p < 0.001). Conclusion: Although currently not an universal practice, substitution of "DM on insulin" with HbA1C:Hemoglobin ratio in RCRI score improves the accuracy of the RCRI risk prediction model in diabetic patients going for non-cardiac surgery.
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Introduction: Post-anaesthesia care unit (PACU) delirium affects 5%-45% of patients after surgery and is associated with postoperative delirium and increased mortality. Up to 40% of PACU delirium is preventable, but it remains under-recognised due to a lack of awareness of its diagnosis. The nursing delirium screening scale (Nu-DESC) has been validated for diagnosing PACU delirium, but is not routinely used locally. This study aimed to use Nu-DESC to establish the incidence and risk factors of PACU delirium in patients undergoing non-cardiac surgery in the surgical population. Methods: We conducted an audit of eligible patients undergoing major surgery in three public hospitals in Singapore over 1 week. Patients were assessed for delirium 30-60 min following their arrival in PACU using Nu-DESC, with a total score of ≥2 indicative of delirium. Results: A total of 478 patients were assessed. The overall incidence rate of PACU delirium was 18/478 (3.8%), and the incidence was 9/146 (6.2%) in patients aged > 65 years. Post-anaesthesia care unit delirium was more common in females, patients with malignancy and those who underwent longer operations. Logistic regression analysis showed that the use of bispectral index (P < 0.001) and the presence of malignancy (P < 0.001) were significantly associated with a higher incidence of PACU delirium. Conclusion: In this first local study, the incidence of PACU delirium was 3.8%, increasing to 6.2% in those aged > 65 years. Understanding these risk factors will form the basis for which protocols can be established to optimise resource management and prevent long-term morbidities and mortality in PACU delirium.
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Anestesia , Delirio , Neoplasias , Femenino , Humanos , Delirio/diagnóstico , Delirio/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Singapur/epidemiología , Estudios Prospectivos , Anestesia/efectos adversos , Factores de RiesgoRESUMEN
Introduction: Major abdominal emergency surgery (MAES) patients have a high risk of mortality and complications. The time-sensitive nature of MAES necessitates an easily calculable risk-scoring tool. Shock index (SI) is obtained by dividing heart rate (HR) by systolic blood pressure (SBP) and provides insight into a patient's haemodynamic status. We aimed to evaluate SI's usefulness in predicting postoperative mortality, acute kidney injury (AKI), requirements for intensive care unit (ICU) and high-dependency monitoring, and the ICU length of stay (LOS). Method: We retrospectively reviewed 212,089 MAES patients from January 2013 to December 2020. The cohort was propensity matched, and 3960 patients were included. The first HR and SBP recorded in the anaesthesia chart were used to calculate SI. Regression models were used to investigate the association between SI and outcomes. The relationship between SI and survival was explored with Kaplan-Meier curves. Results: There were significant associations between SI and mortality at 1 month (odds ratio [OR] 2.40 [1.67-3.39], P<0.001), 3 months (OR 2.13 [1.56-2.88], P<0.001), and at 2 years (OR 1.77 [1.38-2.25], P<0.001). Multivariate analysis revealed significant relationships between SI and mortality at 1 month (OR 3.51 [1.20-10.3], P=0.021) and at 3 months (OR 3.05 [1.07-8.54], P=0.034). Univariate and multivariate analysis also revealed significant relationships between SI and AKI (P<0.001), postoperative ICU admission (P<0.005) and ICU LOS (P<0.001). SI does not significantly affect 2-year mortality. Conclusion: SI is useful in predicting postopera-tive mortality at 1 month, 3 months, AKI, postoperative ICU admission and ICU LOS.
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Lesión Renal Aguda , Unidades de Cuidados Intensivos , Tiempo de Internación , Complicaciones Posoperatorias , Choque , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Tiempo de Internación/estadística & datos numéricos , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Anciano , Unidades de Cuidados Intensivos/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Abdomen/cirugía , Frecuencia Cardíaca/fisiología , Presión Sanguínea/fisiología , Periodo Preoperatorio , Urgencias Médicas , Medición de Riesgo/métodos , Puntaje de Propensión , Singapur/epidemiologíaRESUMEN
The American Society of Anesthesiologists Physical Status Classification (ASA) is used for communication of patient health status, risk scoring, benchmarking and financial claims. Prior studies using hypothetical scenarios have shown poor concordance of ASA classification among healthcare providers. There is a paucity of studies using clinical data, and of clinical factors or patient outcomes associated with discordant classification. The study aims to assess ASA classification concordance between surgeons and anesthesiologists, factors surrounding discordance and its impact on patient outcomes. This retrospective cohort study was conducted in a tertiary medical center on 46,284 consecutive patients undergoing elective surgery between January 2017 and December 2019. The ASA class showed moderate concordance (weighted Cohen's κ 0.53) between surgeons and anesthesiologists. We found significant associations between discordant classification and patient comorbidities, age and race. Patients with discordant classification had a higher risk of 30-day mortality (odds ratio (OR) 2.00, 95% confidence interval (CI) = 1.52-2.62, p < 0.0001), 1-year mortality (OR 1.53, 95% CI = 1.38-1.69, p < 0.0001), and Intensive Care Unit admission > 24 h (OR 1.69, 95% CI = 1.47-1.94, p < 0.0001). Hence, there is a need for improved standardization of ASA scoring and cross-specialty review in ASA-discordant cases.
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Anestesiólogos , Cirujanos , Procedimientos Quirúrgicos Electivos/efectos adversos , Humanos , Oportunidad Relativa , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
Myocardial ischemia-reperfusion injury (MIRI) is a complicated pathologic process that involves multiple factors including oxidative stress (free radical damage), inflammatory response, calcium overloading, and apoptosis in cardiomyocytes. According to Traditional Chinese Medicine (TCM), MIRI belongs to the categories of "chest numbness", "palpitations" and "angina pectoris". Present data indicate that the application of TCM in myocardial ischemia-reperfusion injury is promising and continues to attract research attention. While the efficacy of Chinese herbal medicine has been well-proven, the underlying molecular mechanisms remain elusive. The common proven mechanisms of Chinese herbal medicine in the treatment of MIRI include regulating lipid metabolism, protecting mitochondria, and improving energy metabolism, attenuating calcium (Ca2+) overload, scavenging oxygen free radicals, inhibiting apoptosis, and reducing autophagy. Others are the regulation of inflammatory cytokine expressions and healing of inflammatory lesions, modulation of cell signaling pathways, improvement of endothelial cell function, and protection of myocardial cells. In this review, we highlight recent studies that focus on elucidating these molecular mechanisms and the therapeutic effects of natural compounds deriving from TCM in MIRI, to ascertain the research progress made and the prospects in this field.
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BACKGROUND: Atrial septal shunt devices might improve hospitalizations and also prognosis in heart failure with increased pulmonary pressures due to left heart diseases. In recent years, atrial shunt devices have been used for the treatment of chronic heart failure, but there remains a lack of clinical experience. This study aimed to analyse the therapeutic effect of a novel type of atrial shunt on chronic heart failure. METHODS AND RESULTS: From May 2020 to September 2020, six patients who were diagnosed with chronic heart failure and completed percutaneous D-shant atrium shunt device implantation in the Department of Cardiovascular Surgery, Union Hospital, were retrospectively included. The shunt location was evaluated by echocardiography and digital subtraction angiography. Heart function was evaluated by New York Heart Association functional class. Echocardiography was used to measure the diameter of the new chamber and ventricle, and to evaluate the degree of mitral and tricuspid regurgitation. Before operation and 6 months after operation, left atrial end-diastolic volume, right atrial end-diastolic volume, left ventricular end-diastolic volume, and right ventricular end-diastolic volume were measured by magnetic resonance imaging. Left ventricular ejection fractions and right ventricular ejection fractions were calculated. Haemodynamic indexes of right heart catheterization and clinical cardiac function indexes were collected and compared before and 6 months after shunt implantation. All six patients completed percutaneous shunt device implantation. Echocardiography and digital subtraction angiography showed that the shunt device was correctly positioned and unobstructed in all patients. Echocardiography revealed that the left ventricular diameter decreased significantly from 6.40 ± 0.57 mm to 5.03 ± 0.73 mm (P < 0.05). There was an obvious decrease in mitral regurgitation. Magnetic resonance imaging showed a reduction in the volume of the left ventricle (182.00 ± 27.02 mL vs. 125.75 ± 16.11 mL, P < 0.05). Cardiac catheter examination showed the mean left atrium pressure or pulmonary capillary wedge pressure decreased postoperatively (31.83 ± 11.55 vs. 18.00 ± 5.51 mmHg, P < 0.05). There was also obvious improvement in clinical indicators of cardiac function at 6 months after implantation. CONCLUSIONS: This novel D-shant atrium shunt device revealed maintained good function, no dislodgement and no paradoxical emboli. After implantation, functional mitral regurgitation in all patients with heart failure with reduced ejection fraction improved.
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Insuficiencia Cardíaca , Insuficiencia de la Válvula Mitral , Enfermedad Crónica , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/cirugía , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/cirugía , Humanos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Post-anaesthesia care unit (PACU) delirium is a potentially preventable condition that results in a significant long-term effect. In a multicentre prospective cohort study, we investigate the incidence and risk factors of postoperative delirium in elderly patients undergoing major non-cardiac surgery. METHODS: Patients were consented and recruited from 4 major hospitals in Singapore. Research ethics approval was obtained. Patients older than 65 years undergoing non-cardiac surgery >2 hours were recruited. Baseline perioperative data were collected. Preoperative baseline cognition was obtained. Patients were assessed in the post-anaesthesia care unit for delirium 30-60 minutes after arrival using the Nursing Delirium Screening Scale (Nu-DESC). RESULTS: Ninety-eight patients completed the study. Eleven patients (11.2%) had postoperative delirium. Patients who had PACU delirium were older (74.6±3.2 versus 70.6±4.4 years, P=0.005). Univariate analysis showed those who had PACU delirium are more likely to be ASA 3 (63.6% vs 31.0%, P=0.019), had estimated glomerular filtration rate (eGFR) of >60mL/min/1.73m2 (36.4% vs 10.6%, P=0.013), higher HbA1C value (7.8±1.2 vs 6.6±0.9, P=0.011), raised random blood glucose (10.0±5.0mmol/L vs 6.5±2.4mmol/L, P=0.0066), and moderate-severe depression (18.2% vs 1.1%, P=0.033). They are more likely to stay longer in hospital (median 8 days [range 4-18] vs 4 days [range 2-8], P=0.049). Raised random blood glucose is independently associated with increased PACU delirium on multivariate analysis.
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Anestesia , Delirio , Anciano , Periodo de Recuperación de la Anestesia , Delirio/diagnóstico , Delirio/epidemiología , Delirio/etiología , Humanos , Incidencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Diabetes is a risk factor for postoperative complications. Previous meta-analyses have shown that elevated glycated hemoglobin (HbA1c) levels are associated with postoperative complications in various surgical populations. However, this is the first meta-analysis to investigate the association between preoperative HbA1c levels and postoperative complications in patients undergoing elective major abdominal surgery. METHODS: PRISMA guidelines were adhered to for this study. Six databases were searched up to April 1, 2020. Primary studies investigating the effect of HbA1c levels on postoperative complications after elective major abdominal surgery were included. Risk of bias and quality of evidence assessments were performed. Data were pooled using a random effects model. Meta-regression was performed to evaluate different HbA1c cut-off values. RESULTS: Twelve observational studies (25,036 patients) were included. Most studies received a 'good' and 'moderate quality' score using the NOS and GRADE, respectively. Patients with a high HbA1c had a greater risk of anastomotic leaks (odds ratio [OR]: 2.80, 95% CI [1.63, 4.83], P < 0.001), wound infections (OR: 1.21, 95% CI [1.08, 1.36], P = 0.001), major complications defined as Clavien-Dindo [CD] 3-5 (OR: 2.16, 95% CI [1.54, 3.01], P < 0.001), and overall complications defined as CD 1-5 (OR: 2.12, 95% CI [1.48, 3.04], P < 0.001). CONCLUSIONS: An HbA1c between 6% and 7% is associated with higher risks of anastomotic leaks, wound infections, major complications, and overall postoperative complications. Therefore, guidelines with an HbA1c threshold > 7% may be putting pre-optimized patients at risk. Future randomized controlled trials are needed to explore causation before policy changes are made.
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Diabetes Mellitus , Procedimientos Quirúrgicos Electivos , Abdomen/cirugía , Diabetes Mellitus/epidemiología , Procedimientos Quirúrgicos Electivos/efectos adversos , Hemoglobina Glucada/análisis , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
HbA1C's predictive value for postoperative complications in cardiac surgery has been mixed. Studies did not account for HbA1C being over-read in anemic patients. This study proposes a novel way of using a ratio of HbA1C over hemoglobin (HH ratio). Retrospective recruitment of patients undergoing cardiac surgery was done with ethics approval. The primary objective of our study is to look for the correlation of HH ratio with 90-day (short-term) and 1-year (long-term) mortality. The secondary objective is to investigate its association with other adverse events. Statistical analysis was done using multivariable regressions and Cox proportional hazard models. Of the 974 patients recruited, 618 had a HH Ratio<0.5, 284 between 0.5-0.7 and 72 had the ratio >0.7. HH ratio of 0.5-0.7 and >0.7 was associated with 90-day mortality (HR 5.12, Pâ¯=â¯0.033 and HR 7.25, P= 0.048 respectively) and 1-year mortality (HR 4.53, Pâ¯=â¯0.028 and HR 9.20, Pâ¯=â¯0.022 respectively). The higher HH ratio groups were also associated with increased length of stay (hours) in the intensive care unit (P < 0.001) and renal complications (P < 0.001). Our study showed a positive association of HH ratio with 90-day and 1-year mortality and postoperative adverse outcomes in patients undergoing cardiac surgery. The HH ratio has the potential to be a new perioperative target.
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Anemia , Procedimientos Quirúrgicos Cardíacos , Anemia/diagnóstico , Anemia/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Hemoglobina Glucada , Hemoglobinas , Humanos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Novel coronavirus disease 2019 (COVID-19) has become a worldwide pandemic and precise fatality data by age group is needed urgently. This study to delineate the clinical characteristics and outcome of COVID-19 patients aged ≥75 years and identify the risk factors of in-hospital death. METHODS: A total of 141 consecutive patients aged ≥75 years who were admitted to the hospital between 12th and 19th February 2020. In-hospital death, clinical characteristics and laboratory findings on admission were obtained from medical records. The final follow-up observation was on the 31st March 2020. RESULTS: The median age was 81 years (84 female, 59.6%). Thirty-eight (27%) patients were classified as severe or critical cases. 18 (12.8%) patients had died in hospital and the remaining 123 were discharged. Patients who died were more likely to present with fever (38.9% vs. 7.3%); low percutaneous oxygen saturation (SpO2) (55.6% vs. 7.3%); reduced lymphocytes (72.2% vs. 35.8%) and platelets (27.8% vs. 4.1%); and increased D-dimer (94.4% vs. 42.3%), creatinine (50.0% vs. 22.0%), lactic dehydrogenase (LDH) (77.8% vs. 30.1%), high sensitivity troponin I (hs-TnI) (72.2% vs. 14.6%), and N-terminal pro-brain natriuretic peptide (NT-proBNP) (72.2% vs. 6.5%; all P < 0.05) than patients who recovered. Male sex (odds ratio [OR] = 13.1, 95% confidence interval [CI] 1.1 to 160.1, P = 0.044), body temperature > 37.3 °C (OR = 80.5, 95% CI 4.6 to 1407.6, P = 0.003), SpO2 ≤ 90% (OR = 70.1, 95% CI 4.6 to 1060.4, P = 0.002), and NT-proBNP> 1800 ng/L (OR = 273.5, 95% CI 14.7 to 5104.8, P < 0.0001) were independent risk factors of in-hospital death. CONCLUSIONS: In-hospital fatality among elderly COVID-19 patients can be estimated by sex and on-admission measurements of body temperature, SpO2, and NT-proBNP.
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COVID-19/diagnóstico , COVID-19/mortalidad , Anciano , Anciano de 80 o más Años , Temperatura Corporal , Femenino , Mortalidad Hospitalaria , Hospitalización , Humanos , Masculino , Péptido Natriurético Encefálico/sangre , Oxígeno/sangre , Pandemias , Pronóstico , Estudios Retrospectivos , SARS-CoV-2RESUMEN
INTRODUCTION: Diabetes has an increasing worldwide prevalence. It is known to be a predisposing factor for postoperative complications. Preoperative glycaemic control strategies should be pursued as glycaemic control could serve as a modifiable risk factor. Glycated haemoglobin (HbA1c), a marker of 3-month average glycaemic control, has been shown in meta-analyses to predict postoperative complications in cardiothoracic, bariatric and orthopaedic surgery. However, there is no meta-analysis in the major abdominal surgery population, in whom morbidity may be higher due to the nature of the surgery. Understanding the association between HbA1c and postoperative complications could help in preoperative risk prognostication, counselling and glycaemic target selection. The aim of this systematic review and meta-analysis is to evaluate all evidence on the association between preoperative HbA1c and postoperative complications in elective major abdominal surgery, and to investigate the threshold HbA1c level before postoperative complication rates increase. METHODS AND ANALYSIS: This review will be performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure will be searched for all original studies. Study selection, data extraction, risk of bias and quality assessment will be conducted by two independent reviewers. The primary outcome is the association between preoperative HbA1c and major postoperative complications (Clavien Dindo 3-5), and the secondary outcome is the association between HbA1c and overall postoperative complications. Data management and synthesis will be performed using Microsoft Excel and Stata to derive pool estimates. ETHICS AND DISSEMINATION: No ethics approval is required as only secondary data will be used. Findings will be disseminated through peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42020167347.
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Glucemia , Procedimientos Quirúrgicos Electivos , China , Hemoglobina Glucada , Humanos , Metaanálisis como Asunto , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Revisiones Sistemáticas como AsuntoRESUMEN
This study aimed to evaluate the efficacy of Chinese herbal medicine (CHM) in patients with severe/critical coronavirus disease 2019 (COVID-19). In this retrospective study, data were collected from 662 patients with severe/critical COVID-19 who were admitted to a designated hospital to treat patients with severe COVID-19 in Wuhan before March 20, 2020. All patients were divided into an exposed group (CHM users) and a control group (non-users). After propensity score matching in a 1:1 ratio, 156 CHM users were matched by propensity score to 156 non-users. No significant differences in seven baseline clinical variables were found between the two groups of patients. All-cause mortality was reported in 13 CHM users who died and 36 non-users who died. After multivariate adjustment, the mortality risk of CHM users was reduced by 82.2% (odds ratio 0.178, 95% CI 0.076-0.418; P < 0.001) compared with the non-users. Secondly, age (odds ratio 1.053, 95% CI 1.023-1.084; P < 0.001) and the proportion of severe/critical patients (odds ratio 0.063, 95% CI 0.028-0.143; P < 0.001) were the risk factors of mortality. These results show that the use of CHM may reduce the mortality of patients with severe/critical COVID-19.