Artificial intelligence-assisted interventions for perioperative anesthetic management: a systematic review and meta-analysis.

BACKGROUND: Integration of artificial intelligence (AI) into medical practice has increased recently. Numerous AI models have been developed in the field of anesthesiology; however, their use in clinical settings remains limited. This study aimed to identify the gap between AI research and its implementation in anesthesiology via a systematic review of randomized controlled trials with meta-analysis (CRD42022353727). METHODS: We searched the databases of Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (Embase), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), Institute of Electrical and Electronics Engineers Xplore (IEEE), and Google Scholar and retrieved randomized controlled trials comparing conventional and AI-assisted anesthetic management published between the date of inception of the database and August 31, 2023. RESULTS: Eight randomized controlled trials were included in this systematic review (n = 568 patients), including 286 and 282 patients who underwent anesthetic management with and without AI-assisted interventions, respectively. AI-assisted interventions used in the studies included fuzzy logic control for gas concentrations (one study) and the Hypotension Prediction Index (seven studies; adding only one indicator). Seven studies had small sample sizes (n = 30 to 68, except for the largest), and meta-analysis including the study with the largest sample size (n = 213) showed no difference in a hypotension-related outcome (mean difference of the time-weighted average of the area under the threshold 0.22, 95% confidence interval -0.03 to 0.48, P = 0.215, I2 93.8%). CONCLUSIONS: This systematic review and meta-analysis revealed that randomized controlled trials on AI-assisted interventions in anesthesiology are in their infancy, and approaches that take into account complex clinical practice should be investigated in the future. TRIAL REGISTRATION: This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022353727).

Risk of postoperative pneumonia after extubation with the positive pressure versus normal pressure technique: a single-center retrospective observational study.

PURPOSE: A normal pressure extubation technique (no lung inflation before extubation), proposed by the Japanese Society of Anesthesiologists to prevent droplet infection during the coronavirus disease 2019 (COVID-19) pandemic, could theoretically increase postoperative pneumonia incidence compared with a positive pressure extubation technique (lung inflation before extubation). However, the normal pressure extubation technique has not been adequately evaluated. This study compared postoperative pneumonia incidence between positive and normal pressure extubation techniques using a dataset from the University of Tsukuba Hospital. METHODS: In our hospital, the extubation methods changed from positive to normal pressure extubation techniques on March 3, 2020 due to the COVID-19 pandemic. Thus, we compared the risk of postoperative pneumonia between the positive (April 1, 2017 to December 31, 2019) and normal pressure extubation techniques (March 3, 2020 to March 31, 2022) using propensity score analyses. Postoperative pneumonia was defined using the International Classification of Diseases, 10th Edition (ICD-10) codes (J13-J18), and we reviewed the medical records of patients flagged with these ICD-10 codes (preoperative pneumonia and ICD-10 codes for prophylactic antibiotic prescriptions for pneumonia). RESULTS: We identified 20,011 surgeries, including 11,920 in the positive pressure extubation group (mean age 48.2 years, standard deviation [SD] 25.2 years) and 8,091 in the normal pressure extubation group (mean age 47.8 years, SD 25.8 years). The postoperative pneumonia incidences were 0.19% (23/11,920) and 0.17% (14/8,091) in the positive and normal pressure extubation groups, respectively. The propensity score analysis using inverse probability weighting revealed no significant difference in postoperative pneumonia incidence between the two groups (adjusted odds ratio 0.98, 95% confidence interval 0.50 to 1.91, P = 0.94). CONCLUSIONS: These results indicated no increased risk of postoperative pneumonia associated with the normal pressure extubation technique compared with the positive pressure extubation technique. CLINICAL TRIAL NUMBER: Clinical trial number: UMIN000048589 https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000055364.

Multivariate generalized mixed-effects models for screening multiple adverse drug reactions in spontaneous reporting systems.

Introduction: For assessing drug safety using spontaneous reporting system databases, quantitative measurements, such as proportional reporting rate (PRR) and reporting odds ratio (ROR), are widely employed to assess the relationship between a drug and a suspected adverse drug reaction (ADR). The databases contain numerous ADRs, and the quantitative measurements need to be calculated by performing the analysis multiple times for each ADR. We proposed a novel, simple, and easy-to-implement method to estimate the PRR and ROR of multiple ADRs in a single analysis using a generalized mixed-effects model for signal detection. Methods: The proposed method simultaneously analyzed the association between any drug and numerous ADRs, as well as estimated the PRR and ROR for a specific combination of drugs and suspected ADRs. Furthermore, the proposed method was applied to detect drug-drug interactions associated with the concurrent use of two or more drugs. Results and discussion: In our simulation studies, the false-positive rate and sensitivity of the proposed method were similar to those of the traditional PRR and ROR. The proposed method detected known ADRs when applied to the Food and Drug Administration Adverse Event Reporting System database. As an important advantage, the proposed method allowed the simultaneous evaluation of several ADRs using multiple drugs.

Three-dimensional analysis reveals a high incidence of lung adenocarcinoma in the upper region.

PURPOSE: The lung is a unique organ with a ventilation-perfusion mismatch, which can cause inhomogeneous incidence rates of lung cancer depending on the location in the lung. We aimed to evaluate the incidence of lung adenocarcinoma in each lobe by analyzing the incidence per unit volume, to evaluate the incidence without being affected by differences in the size of each lobe or in the size of the lungs between individuals. METHODS: The number of adenocarcinomas in each lobe was counted. Lung volumes were measured using a three-dimensional computer workstation. The tumor incidence per unit volume was analyzed based on the number of tumors in each lobe. RESULTS: The number of tumors per unit volume was 0.467 in the right upper lobe (RUL), 0.182 in the right middle lobe, 0.209 in the right lower lobe, 0.306 in the left upper segment (LUS), 0.083 in the left lingular segment, and 0.169 in the left lower lobe. The tumor incidence rate of RUL + LUS was 2.269 times that of the other lobes, a value that was significantly higher when using the bootstrap method (p < 0.001). CONCLUSIONS: The incidence of adenocarcinoma per unit volume in both upper lobes was higher than that in other lobes.

Effect of cardiopulmonary bypass on coagulation factors II, VII and X in a primate model: an exploratory pilot study.

OBJECTIVES: The use of cardiopulmonary bypass (CPB) in cardiac surgery is a major risk factor for postoperative bleeding. We hypothesized that consumptive coagulopathy and haemodilution influence the coagulation factors; therefore, we aimed to estimate the activity profiles of coagulation factors II, VII and X during CPB circulation. METHODS: A 120-min bypass was surgically established in cynomolgus monkeys (n = 7). Activities of coagulation factors II, VII and X were measured at 6 time points during the experiment (baseline, 0, 30, 60, 120 min of bypass and 60 min after bypass). To assess the influence of consumptive coagulopathy, the values were adjusted for haemodilution using the haematocrit values. Data were expressed as mean (standard deviation). RESULTS: Activities of coagulation factors decreased during the experiment. In particular, the activities for II, VII and X were decreased the most by 44.2% (5.0), 61.4% (4.3) and 49.0% (3.7) at 30 min following CPB initiation (P < 0.001, P < 0.001 and P < 0.001, respectively). Following adjustments for haemodilution, change magnitudes lessened but remained significant for factor VII. The adjusted concentration of factor VII was observed to decrease from the baseline to the initiation of bypass circulation. CONCLUSIONS: In conclusion, coagulation factor II, VII and X concentrations decreased during CPB. Following adjustment for haemodilution, a decrease in concentration was observed with factor VII.

Safety of romiplostim administered immediately after cord-blood transplantation: a phase 1 trial.

Graft failure and delayed hematopoietic recovery are the major limitations of cord-blood transplantation (CBT). Romiplostim, a thrombopoietin-receptor agonist, promotes megakaryopoiesis and multilineage hematopoiesis in aplastic anemia. The decreased number of hematopoietic stem cells in the early phase after CBT and aplastic anemia share certain characteristics. Therefore, we hypothesized that romiplostim administration immediately after CBT may promote multilineage hematopoietic recovery. We investigated the safety and preliminary efficacy of administering romiplostim a day after CBT. This phase 1 dose-escalation study included six adults with hematologic malignancies in remission. Romiplostim was administered subcutaneously within 7 days after single-unit CBT, initially at doses of 5 µg/kg or 10 µg/kg in three patients, then once a week for 14 weeks or until platelet recovery. The maximum dose was 20 µg/kg. The median number of romiplostim administrations was 6 (range, 3-15). Romiplostim-related adverse events included bone pain (3/6) and injection site reaction (1/6). Non-hematological grade ≥ 3 toxicities were observed in four patients; febrile neutropenia was the most common (4/6). All patients achieved neutrophil engraftment and the median time was 14 days (range, 12-32). Platelet counts ≥ 50 × 109 /L were recorded in all patients except for one who died on day 48; the median time was 34 days (range, 29-98). No relapse, thrombosis, or bone marrow fibrosis was observed during a median follow-up of 34 months. Romiplostim may be safely administered in the early phase of CBT. Further phase 2 trial is warranted for its efficacy evaluation. Trial registration number: UMIN000033799, August 18, 2018.

Bias in Odds Ratios From Logistic Regression Methods With Sparse Data Sets.

BACKGROUND: Logistic regression models are widely used to evaluate the association between a binary outcome and a set of covariates. However, when there are few study participants at the outcome and covariate levels, the models lead to bias of the odds ratio (OR) estimated using the maximum likelihood (ML) method. This bias is known as sparse data bias, and the estimated OR can yield impossibly large values because of data sparsity. However, this bias has been ignored in most epidemiological studies. METHODS: We review several methods for reducing sparse data bias in logistic regression. The primary aim is to evaluate the Bayesian methods in comparison with the classical methods, such as the ML, Firth's, and exact methods using a simulation study. We also apply these methods to a real data set. RESULTS: Our simulation results indicate that the bias of the OR from the ML, Firth's, and exact methods is considerable. Furthermore, the Bayesian methods with hyper-É¡ prior modeling of the prior covariance matrix for regression coefficients reduced the bias under the null hypothesis, whereas the Bayesian methods with log F-type priors reduced the bias under the alternative hypothesis. CONCLUSION: The Bayesian methods using log F-type priors and hyper-É¡ prior are superior to the ML, Firth's, and exact methods when fitting logistic models to sparse data sets. The choice of a preferable method depends on the null and alternative hypothesis. Sensitivity analysis is important to understand the robustness of the results in sparse data analysis.

Intravenous Tranexamic Acid in Percutaneous Kidney Biopsy: A Randomized Controlled Trial.

BACKGROUND: Tranexamic acid is frequently reported to reduce bleeding-related complications in major surgery and trauma. We aimed to investigate whether tranexamic acid reduced hematoma size after percutaneous kidney biopsy. METHODS: We conducted a double-blind, parallel three-group, randomized placebo-controlled trial at a teaching hospital in Japan between January 2016 and July 2018. Adult patients with clinical indication for ultrasound-guided percutaneous biopsy of a native kidney were included. Participants were randomly assigned into three groups: high-dose tranexamic acid (1,000 mg in total), low-dose tranexamic acid (500 mg in total), or placebo (counterpart saline). Intervention drugs were intravenously administered twice, as a bolus just before the biopsy and as a continuous infusion initiated just after the biopsy. Primary outcome was post-biopsy perirenal hematoma size as measured by ultrasound on the morning after the biopsy. RESULTS: We assessed 90 adult patients for study eligibility, of whom 56 were randomly allocated into the three groups: 20 for high-dose tranexamic acid, 19 for low-dose tranexamic acid, and 17 for placebo. The median size of perirenal hematoma was 200 mm2 (interquartile range, 21-650) in the high-dose tranexamic acid group, 52 mm2 (0-139) in the low-dose tranexamic acid group, and 0 mm2 (0-339) in the placebo group (p = 0.048 for high-dose tranexamic acid vs. placebo). CONCLUSION: In this trial, the median size of post-kidney biopsy hematoma was unexpectedly larger in the high-dose tranexamic acid group than in the placebo group. Although our results do not support the routine use of tranexamic acid in percutaneous kidney biopsy at present, further studies are needed to confirm the results.

Effectiveness of an online support program to help female cancer patients manage their health and illness: Protocol for a randomized controlled trial.

Background: The aim of the trial is to evaluate the effectiveness of interventions provided by online support program apps, adopting health-related quality of life (HR-QOL) scores as indicators. Methods: The design is as an open, randomized, parallel-group trial with longitudinal data collection. The subjects will be female cancer patients receiving treatment in a Japanese National Cancer Hospital. Patients assigned to the experimental group will use three apps: an app for them to monitor their own health (monitoring app), an app to assess their understanding of their diagnosis and treatment and their readiness to receive treatment (confirmation app), and an app to address mental health issues (writing app); patients assigned to the control group will use only the monitoring app. At baseline (before patients undergo cancer treatment) and three other times during the study, evaluation indicators will be obtained from three different standardized HR-QOL scales that are incorporated in the monitoring app. The study hypothesis is that at 6 months after patients' baseline health monitoring, patients in the experimental group will have improved HR-QOL as compared with patients in the control group. Conclusion: This study is based on self-regulation theory, so it is important that the online support program works in an efficient way with respect to patients finding and setting their own health-related goals and adapting their behaviors to achieve those goals. Verifying the effectiveness of the combination of the three apps will show that it is a scientifically valid approach to maintaining or improving the HR-QOL of cancer patients.

A Smartphone Healthcare Application, CALO mama Plus, to Promote Weight Loss: A Randomized Controlled Trial.

Mobile applications are increasingly used in healthcare. We have developed a smartphone healthcare application, CALO mama Plus, that can register daily diet, exercise, mood, and sleep quality, calculate dietary intake, and provide advice using artificial intelligence technology. This 3-month randomized controlled trial tested the hypothesis that CALO mama Plus could promote body weight reduction in Japanese adults with overweight or obesity. We recruited office workers as participants. The key eligibility criteria were an age of 20-65 years and a body mass index of 23-40 kg/m2. The primary outcome was body weight change over 3 months. We enrolled 141 participants and randomly assigned them to the intervention (n = 72) and control (n = 69) groups. The intervention group used CALO mama Plus, and the control group did not receive any intervention. The change in body weight was -2.4 ± 4.0 kg and -0.7 ± 3.3 kg in the intervention and control groups, respectively. An analysis of covariance adjusted for related variables showed a significant between-group difference in body weight change (-1.60 kg; 95% confidence interval -2.83 to -0.38; p = 0.011). The present study suggests that CALO mama Plus effectively promotes weight loss.

Identification of High-Risk Groups in Urinalysis: Lessons from the Longitudinal Analysis of Annual Check-Ups.

BACKGROUND: For effective screening in urinalysis, information on high-risk groups is needed; however, there is a lack of evidence in young adults in particular. The aim of this study was to provide information on urinalysis in young adults and to identify high-risk groups of urinalyses using multi-year data obtained from annual large-scale check-ups. METHOD: We used annual health check-up data collected from 2011 to 2016 at Kyoto University in Japan. Eligible participants were those aged 18-39 years who underwent annual health check-ups for four consecutive years between 2011 and 2016. We conducted descriptive analyses and calculated the risk ratios (RRs) for urinary abnormalities in the fourth year of urinalysis. RESULTS: In total, 13,640 participants (10,877 men, 79.7%) met the eligibility criteria. The mean prevalence rates of proteinuria, haematuria and glucosuria were 1.61% (men: 1.63%; women: 1.53%), 1.48% (men: 0.53%; women: 5.22%) and 0.46% (men: 0.52%; women: 0.25%), respectively. Participants with urinary abnormalities at least once in the initial 3 years had a higher risk of urinary abnormalities in the fourth year than participants with no abnormal findings in the initial 3 years; the risk ratios (RRs) of proteinuria, haematuria and glucosuria were 3.5 (95% confidence interval (CI) = 3.2-3.7), 12.2 (95% CI = 11.7-12.7) and 42.6 (95% CI = 37.7-48.1), respectively. The RRs of all urinary abnormalities in the fourth year increased as the frequency of urinary abnormalities over the preceding 3 years increased. In haematuria, differences of the RR were observed between men and women. CONCLUSION: We clarified the prevalence of urinary abnormalities in young adults and high-risk groups of urinary abnormalities. Our findings support the need for multi-year annual urinalysis.

Using horseshoe prior for incorporating multiple historical control data in randomized controlled trials.

Meta-analytic approaches and power priors are often used to incorporate historical controls into the analysis of a current randomized controlled trial. In this study, we propose a method for incorporating multiple historical controls based on a horseshoe prior, which is a type of global-local shrinkage prior. The method assumes that historical controls follow the same distribution as the current control. In the case in which only a few historical controls are heterogeneous, we consider them to follow a potentially biased distribution from the distribution of the current control. We analyze two clinical trial examples with binary and time-to-event endpoints and conduct simulation studies to compare the performance of the proposed and existing methods. In the analysis of the clinical trial example, the posterior standard deviation of the treatment effect is decreased by the proposed method by considering the bias between the current control and heterogeneous historical control. In the scenarios in which the current and historical controls follow the same distribution, the statistical power using the proposed method is higher than that using existing methods. The proposed method is advantageous when few or no heterogeneous historical controls are expected.

Patient-controlled epidural analgesia, patient-controlled intravenous analgesia, and conventional intravenous opioids for gynecologic interstitial brachytherapy: A single-center retrospective study.

PURPOSE Interstitial brachytherapy for gynecologic malignancies is stressful physically and mentally; however, optimal analgesic methods remain unclear. We investigated the effect of analgesic methods on pain and adverse events during interstitial brachytherapy for gynecologic malignancies. METHODS The data of 73 patients who underwent interstitial brachytherapy for gynecologic malignancies between April 2015 and March 2020 were retrospectively analyzed. Patient-controlled epidural analgesia (PCEA), patient-controlled intravenous analgesia (PCIA), and conventional intravenous opioid administration were used for analgesia during treatment. We compared the analgesic effects based on a numerical rating scale (NRS), the number of additional analgesics, and the adverse events associated with analgesia. The NRS score was calculated as an average value for every 12 h (NRS1: treatment on the 1st day from 12 to 24 o'clock; NRS2: treatment on the 2nd day from 0 to 12 o'clock; NRS3: treatment on the 2nd day from 12 to 24 o'clock). The mean NRS score differences between the methods were evaluated using mixed models for repeated-measures analyses. RESULTS The NRS score was significantly lower at all times for PCEA (NRS1: p = 0.003; NRS2: p = 0.011; NRS3: p < 0.001). NRS2 and NRS3 were significantly lower for PCIA (NRS2: p = 0.043; NRS3: p < 0.001) than for the conventional method. The NRS scores for PCEA and PCIA were not significantly different. Moreover, additional analgesics and adverse events did not differ between the three treatments. CONCLUSION PCEA and PCIA were superior to conventional intravenous opioids for analgesia in interstitial brachytherapy for gynecologic malignancies. However, adverse events associated with PCEA and PCIA were not reduced.

Optimal interruption time of dabigatran oral administration to ablation (O-A time) in patients with atrial fibrillation: Integrated analysis of 2 randomized controlled clinical trials.

BACKGROUND: RE-CIRCUIT (NCT02348723) and ABRIDGE-J (UMIN000013129) are recently published randomized clinical trials showing that anticoagulation therapy with dabigatran during the periprocedural period of catheter ablation (CA) for atrial fibrillation (AF) was associated with fewer complications. However, the dabigatran administration protocols were different (uninterrupted in RE-CIRCUIT and minimally interrupted in ABRIDGE-J). The aim of this present study was to clarify the optimal interruption time of dabigatran Oral administration to Ablation (O-A time). METHODS: We conducted an integrated analysis of the 2 prospective trials. The endpoint of the study was the incidence of major bleeding events during and up to 8 weeks after CA across participants with different O-A times. RESULTS: The 535 patients in the dabigatran groups of the 2 trials were divided into 3 groups based on their O-A times (<8 h, n = 258; 8-24 h, n = 191; >24 h, n = 86). Major bleeding events occurred in 5 patients (1.9%) in the <8 h group, and 3 (3.5%) in the >24 h group; however, no major bleeding events occurred in the 8-24 h group (3 group-comparison, p = 0.026). No thromboembolic complication was observed in any of the 3 O-A time groups. CONCLUSION: In patients undergoing CA for AF using dabigatran as a periprocedural anticoagulant, an O-A time of 8-24 h was associated with no bleeding complications. These data suggest that an O-A time of 8-24 h may be an appropriate option, especially in a low thromboembolic-risk patient.

Short-duration triple antithrombotic therapy for atrial fibrillation patients who require coronary stenting: results of the SAFE-A study.

AIMS: We aimed to determine whether shortening the duration of P2Y12 inhibitor therapy can reduce the risk of bleeding without increasing the risk of major adverse cardiovascular events following coronary stenting in patients with atrial fibrillation (AF). METHODS AND RESULTS: The SAFE-A is a randomised controlled trial that compared one-month and six-month P2Y12 inhibitor therapy, in combination with aspirin and apixaban for patients with AF who require coronary stenting. The primary endpoint was the incidence of any bleeding events, defined as Thrombolysis In Myocardial Infarction major/minor bleeding, bleeding with various Bleeding Academic Research Consortium grades, or bleeding requiring blood transfusion within 12 months after stenting. The study aimed to enrol 600 patients but enrolment was slow. Enrolment was terminated prematurely after enrolling 210 patients (72.7±8.2 years; 81% male). The incidence of the primary endpoint did not differ between the one-month and six-month groups (11.8% vs 16.0%; hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.33-1.47; p=0.35). CONCLUSIONS: The study evaluated the safety of withdrawing the P2Y12 inhibitor from triple antithrombotic prescription one month after coronary stenting. However, enrolment was prematurely terminated because it was slow. Therefore, statistical power was not sufficient to assess the differences in the primary endpoint.

SignalDetDDI: An SAS macro for detecting adverse drug-drug interactions in spontaneous reporting systems.

Statistical methods for detecting adverse drug reactions (ADRs) resulting from drug-drug interactions (DDIs) have been used in recent years to analyze the datasets in spontaneous reporting systems. We provide the SignalDetDDI macro in SAS to calculate the criteria for detecting ADRs resulting from the concomitant use of two drugs. We outline two criteria for detecting DDIs with the combination of two drugs and illustrate the implementation of the macro by way of an example. To implement the macro, a user specifies the target ADR and the two drugs to be evaluated. The SignalDetDDI macro outputs a table showing the number of reports on ADRs, the values of the two criteria for detecting ADRs, and the presence of DDIs. This macro enables users to easily and automatically assess the clinical DDIs that result from ADRs. The SignalDetDDI macro is freely available in the Supporting Information.