Does surgery improve quality of life in patients with ongoing- or recurrent diverticulitis; a systematic review and meta-analysis.

BACKGROUND: Recurrences or persistent symptoms after an initial episode of diverticulitis are common, yet surgical treatment is rarely performed. Current guidelines lack clear recommendations on whether or not to operate, even though recent studies suggest an improved quality of life following surgery. The aim of this study is therefore to compare quality of life in patients with recurrent or ongoing diverticulitis treated conservatively versus surgically, giving a more definitive answer to the question of whether or not to operate on these patients. METHODS: A systematic literature search was conducted in EMBASE, MEDLINE and Cochrane. Only comparative studies reporting on quality of life were included. Statistical analysis included calculation of weighted mean differences and pooled odds ratios. RESULTS: Five studies were included; two RCT's and three retrospective observational studies. Compared to conservative treatment, the SF-36 scores were higher in the surgically treated group at each follow-up moment but only the difference in SF-36 physical scores at six months follow-up was statistically significant (MD 6.02, 95%CI 2.62-9.42). GIQLI scores were also higher in the surgical group with a MD of 14.01 (95%CI 8.15-19.87) at six months follow-up and 7.42 (95%CI 1.23-12.85) at last available follow-up. Also, at last available follow-up, significantly fewer recurrences occurred in the surgery group (OR 0.10, 95%CI 0.05-0.23, p < 0.001). CONCLUSION: Although surgery for recurrent diverticulitis is not without risk, it might improve long-term quality of life in patients suffering from recurrent- or ongoing diverticulitis when compared to conservative treatment. Therefore, it should be considered in this patient group.

The impact of COVID-19 on surgical cases at a large quaternary referral hospital.

Introduction: Coronavirus-19 (COVID) stressed healthcare systems by increasing hospital admissions and in-hospital mortality. The impact of COVID on surgical patients is unknown. The purpose of this study was to evaluate how the COVID pandemic affected surgical patients at a large quaternary referral hospital. Methods: A retrospective review of patients undergoing surgical procedures was performed to evaluate patients undergoing surgery. The impact of COVID on surgical patients was divided into four timeframes based on government regulations: pre-COVID (January 1, 2020 to March 15, 2020), suspended (March 16, 2020 to May 4, 2020), backlogged cases (May 5, 2020 to June 14, 2020), and restoration (June 15, 2020 to September 30, 2020). Differences between patient characteristics and outcomes during these timeframes were evaluated. Results: A total of 21,424 surgical cases were performed between January 1, 2020 and September 30, 2020. During the suspended timeframe (when all elective cases were cancelled), the percentage of surgeries increased in men (53.8% compared to 49.2% pre-COVID; P < 0.01), in Black and Hispanic patients (23.1% and 15.3%, respectively; P < 0.05), and in Medicaid and self-pay patients (16.3% compared to 9.9% pre-COVID; P < 0.01). All service lines experienced similar trends in overall case volume except obstetrics (constant), trauma, vascular, and thoracic (which increased during the suspended timeframe). Conclusions: COVID-19 induced stresses in surgical patients, altering payor mix and impacting minority groups at a large quaternary referral hospital.

Barbed versus conventional suture in elective posterior spine surgery.

PURPOSE: Barbed sutures are tissue control devices that can reduce operating room time and costs. We analyzed the utility of barbed sutures in posterior spinal surgery in order to prove non-inferiority to conventional methods for wound closure. METHODS: A cohort of patients undergoing elective posterior spinal surgery in which barbed (prospective) versus conventional sutures (retrospective) were used was analyzed. The primary endpoint was the occurrence of wound healing complications or the need for surgical revision. Secondary endpoints included postoperative stay, readmission rate, and duration and cost of wound closure. RESULT: A total of 483 patients participated in the study, 183 in the Barbed group and 300 in the Conventional group. Wound dehiscence or seroma occurred in 3.8% and 2.7% of the Barbed and Conventional groups, respectively (p = 0.6588). Both superficial (1.6% versus 4.0%, P = 0.2378) and deep infections (2.7% versus 4.7%, p = 0.4124) occurred similarly in both groups. Overall, the rate of re-intervention due to wound healing problems was also similar (4.9% versus 5.3%, p = 0.9906), as well as, total median hospital stay, postoperative stay and 30-day re-admission rates. The average duration of wound closure (1.66 versus 4.16 min per level operated, p < 0.0001) strongly favored the Barbed group. The mean cost of wound closure per patient was higher in the Barbed group (43.23 € versus 22.67 €, p < 0.0001). CONCLUSIONS: In elective posterior spinal procedures, the use of barbed sutures significantly reduced the duration of wound closure. The wound healing process was not hindered and the added cost related to the suture material was small.

Exploring the Landscape of General Surgery in the Adolescent Age Group: Challenges and Considerations.

INTRODUCTION: The adolescent age group typically ranges from 10 to 19 years. This age group differs from the paediatric and adult populations based on their physiological, psychological, and social behaviour. Patients of this age group usually present with trauma, swellings, burns, hernias, hydroceles, haemorrhoids, fibroadenomas, abscesses, pilonidal diseases, etc. The objective of this study was to identify various causes requiring surgical intervention in adolescent patients and to determine the demography of these patients, reasons for surgery, and surgical outcomes in the patients of the adolescent age group. MATERIALS AND METHODS: This single-centre, hospital record-based, retrospective, cross-sectional study was conducted on 445 adolescent patients who underwent various general surgical interventions from August 2022 to July 2023 in the Department of General Surgery, Rajendra Institute of Medical Sciences (RIMS), Ranchi. RESULTS: A total of 445 patients were included in this study; among them, 277 underwent elective surgeries and 168 emergency surgeries. Major surgeries included 315 patients, while 130 were daycare procedures. Males were 294, and 151 were females. Cyst excision was the most performed, followed by fibroadenoma excision. Burn (10.78%) was the most common cause requiring major intervention, followed by intestinal obstruction (6.96%) and perforation (6.51%). Mortality was observed in 6.51% of patients. CONCLUSION: In this study, the adolescent age group required more elective surgical care as compared to emergency care. Among major surgeries, abdominal laparotomy was most common, and in daycare procedures as well as overall, cyst excision was most performed.

Elective surgery for liver injury and misinserted tube into the inferior vena cava associated with chest tube replacement: A case report.

Background: Several reports on organ injury and death due to incorrect chest tube insertion exist; however, reports on the chest tube penetrating the liver and reaching the inferior vena cava are limited. Case Presentation: A 79-year-old man presented with a clamped tube because of massive bleeding from the tube following right chest tube replacement in the hospital of origin. The tube entered the inferior vena cava from the hepatic parenchyma via the right hepatic vein and was removed 15 h later because his hemodynamics stabilized. A ruptured pseudoaneurysm necessitated further transcatheter arterial embolism on the second hospitalization day, and the patient was transferred back to the referring hospital on day 17. Conclusion: Liver injury caused by an inferior vena cava misinsertion-associated chest tube can be treated with elective surgery in anticipation of the tube's tamponade effect. However, due to the risk of rebleeding, imaging follow-up is necessary soon after surgery.

Efficacy and safety of ciprofol versus propofol for anesthesia induction in adult patients received elective surgeries: a meta­analysis.

BACKGROUND: Propofol is use widely used in anesthesia, known for its effectiveness, may lead to cardiopulmonary issues in some patients. Ciprofol has emerged as a possible alternative to propofol because it can achieve comparable effects to propofol while causing fewer adverse events at lower doses. However, no definitive conclusion has been reached yet. This meta-analysis aimed to evaluate the efficacy and safety of ciprofol versus propofol in adult patients undergoing elective surgeries under general anesthesia. METHODS: We searched PubMed, EMBASE, the Cochrane library, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) to identify potentially eligible randomized controlled trials (RCT) comparing ciprofol with propofol in general anesthesia until September 30, 2023. The efficacy outcomes encompassed induction success rate, time to onset of successful induction, time to disappearance of eyelash reflex, and overall estimate means in Bispectral Index (BIS). Safety outcomes were assessed through time to full alertness, incidence of hypotension, incidence of arrhythmia, and incidence of injection-site pain. Continuous variables were expressed as mean difference (MD) with 95% confidence interval (CI), and dichotomous variables were expressed as risk ratio (RR) with 95% CI. Statistical analyses were performed using RevMan 5.4 and STATA 14.0. The quality of the evidence was rated through the grading of recommendations, assessment, development and evaluation (GRADE) system. RESULTS: A total of 712 patients from 6 RCTs were analyzed. Meta-analysis suggested that ciprofol was equivalent to propofol in terms of successful induction rate, time to onset of successful induction, time to disappearance of eyelash reflex, time to full alertness, and incidence of arrhythmia, while ciprofol was better than propofol in overall estimated mean in BIS (MD: -3.79, 95% CI: -4.57 to -3.01, p < 0.001), incidence of hypotension (RR: 0.63, 95% CI: 0.42 to 0.94, p = 0.02), and incidence of injection-site pain (RR: 0.26, 95% CI: 0.14 to 0.47, p < 0.001). All results were supported by moderate to high evidence. CONCLUSIONS: Ciprofol may be a promising alternative to propofol because it facilitates achieving a satisfactory anesthesia depth and results in fewer hypotension and injection-site pain. However, we still recommend conducting more studies with large-scale studies to validate our findings because only limited data were accumulated in this study. TRIAL REGISTRATION: PROSPERO 2023 CRD42023479767.

Impact of Omicron variant infection on the liver, kidney, and coagulation system in patients undergoing elective surgery: a retrospective case-control study.

Purpose: We aimed to investigate the impact of Omicron variant infection on the perioperative organ function in patients undergoing elective surgery. Methods: A total of 5029 patients who underwent elective surgery between October 2022 and January 2023 at our hospital were enrolled. Among them, the patients who underwent elective surgery between October 2022 and November 2022 composed Group 1 (not infected with the Omicron variant) the control group; those who underwent elective surgery between December 2022 and January 2023 composed Group 2 (one month after Omicron variant infection) the experimental group. We further divided the patients into two subgroups for analysis: the tumor subgroup and the nontumor subgroup. Data on organ system function indicators, including coagulation parameters, liver function, complete blood count (CBC), and kidney function, were collected before and after surgery. Differences between the two groups were subsequently analyzed via binary logistic regression analysis. Results: Compared with those in the uninfected patient group, the following changes were observed in patients with Omicron variant infection who underwent elective surgery one month after infection: prothrombin activity (PTa), prothrombin time (PT), fibrinogen, albumin/globulin, alanine aminotransferase (ALT), mean corpuscular hemoglobin concentration (MCHC), platelet (PLT), and anemia were increased AST/ALT, indirect bilirubin (IBILI), eosinophils, and uric acid were decreased before surgery; and lung infection/pneumonia and fibrinogen were increased, while AST/ALT, globulin, total bilirubin (TBIL), white blood cell count (WBC), and uric acid were decreased after surgery. There was no significant difference in the mortality rate or length of hospital stay (LOS) between the two groups. Subgroup analysis revealed elevated monocyte, PLT, and fibrinogen classification, levels and decreased globulin, prealbumin (PBA), eosinophil, and uric acid levels in the tumor subgroup of patients who underwent elective surgery one month after Omicron infection compared with those in the uninfected patients. Compared with the nontumor subgroup, fibrinogen levels, lung infection/pneumonia, TBIL, and PLT count were increased in the uninfected patients, while the globulin and eosinophil levels were decreased. Conclusion: Compared with uninfected patients, patients who underwent elective surgery one month after Omicron variant infection exhibited minimal changes in perioperative coagulation parameters, liver function, CBC counts, and kidney function. Additionally, no significant differences in postoperative mortality or LOS were observed between the two groups.

The impact of SARS-Cov-2 Omicron infection on short-term outcomes after elective surgery in patients with gastrointestinal cancer.

With the emergence of novel variants, Omicron variant caused a different clinical picture than the previous variants and little evidence was reported regarding perioperative outcomes after Omicron variants. The aim of the study was to evaluate the postoperative outcomes of gastrointestinal cancer patients following Omicron variants infection and also to determine the timing of surgery after infection recovery. A total of 124 patients who underwent gastrointestinal cancer surgery with prior SARS-CoV-2 infection between December 2022 and February 2023 were retrospectively reviewed. 174 cases underwent the same operation during December 2018 and February 2019 as control group. SARS-CoV-2-infected patients were further categorized into three groups based on infected time (1-3 weeks; 4-6 weeks; and ≥ 7 weeks). 90.3% of SARS-CoV-2-infected patients had mild symptoms. The COVID-19 vaccination rate was 71.0%, with a full vaccination rate of 48.4%. There were no significant differences in 30-day morbidity and mortality. There was also no significant difference in pulmonary complications, cardiovascular complications, and surgical complications between the three different diagnosis time groups. In conclusion, reducing waiting time for elective surgery was safe for gastrointestinal cancer patients in the context of an increased transmissibility and milder illness severity with Omicron variant.

Risk factors of emergency department visits following elective cervical and lumbar surgical procedures: a multi-institution analysis from the Michigan Spine Surgery Improvement Collaborative.

OBJECTIVE: Emergency department visits 90 days after elective spinal surgery are relatively common, with rates ranging from 9% to 29%. Emergency visits are very costly, so their reduction is of importance. This study's objective was to evaluate the reasons for emergency department visits and determine potentially modifiable risk factors. METHODS: This study retrospectively reviewed data queried from the Michigan Spine Surgery Improvement Collaborative (MSSIC) registry from July 2020 to November 2021. MSSIC is a multicenter (28-hospital) registry of patients undergoing cervical and lumbar degenerative spinal surgery. Adult patients treated for elective cervical and/or lumbar spine surgery for degenerative pathology (spondylosis, intervertebral disc disease, low-grade spondylolisthesis) were included. Emergency department visits within 90 days of surgery (outcome measure) were analyzed utilizing univariate and multivariate regression analyses. RESULTS: Of 16,224 patients, 2024 (12.5%) presented to the emergency department during the study period, most commonly for pain related to spinal surgery (31.5%), abdominal problems (15.8%), and pain unrelated to the spinal surgery (12.8%). On multivariate analysis, age (per 5-year increase) (relative risk [RR] 0.94, 95% CI 0.92-0.95), college education (RR 0.82, 95% CI 0.69-0.96), private insurance (RR 0.79, 95% CI 0.70-0.89), and preoperative ambulation status (RR 0.88, 95% CI 0.79-0.97) were associated with decreased emergency visits. Conversely, Black race (RR 1.30, 95% CI 1.13-1.51), current diabetes (RR 1.13, 95% CI 1.01-1.26), history of deep venous thromboembolism (RR 1.28, 95% CI 1.16-1.43), history of depression (RR 1.13, 95% CI 1.03-1.25), history of anxiety (RR 1.32, 95% CI 1.19-1.46), history of osteoporosis (RR 1.21, 95% CI 1.09-1.34), history of chronic obstructive pulmonary disease (RR 1.19, 95% CI 1.06-1.34), American Society of Anesthesiologists class > II (RR 1.18, 95% CI 1.08-1.29), and length of stay > 3 days (RR 1.29, 95% CI 1.16-1.44) were associated with increased emergency visits. CONCLUSIONS: The most common reasons for emergency department visits were surgical pain, abdominal dysfunction, and pain unrelated to index spinal surgery. Increased focus on postoperative pain management and bowel regimen can potentially reduce emergency visits. The risks of diabetes, history of osteoporosis, depression, and anxiety are areas for additional preoperative screening.

The impact of rising NHS waiting list times on elective surgery for Dupuytren's disease.

Waiting lists for elective surgery are increasing in the United Kingdom. We report a single-centre experience of disease progression of Dupuytren's disease while on the waiting list for surgery and its effect on the type of operative treatment required.

Comparison of the performance of the AUB-HAS2 Cardiovascular Risk Index in emergency vs elective surgeries.

BACKGROUND: The AUB-HAS2 Cardiovascular Risk Index is a newly derived tool for preoperative cardiovascular evaluation. It is based on six data elements: history of heart disease, symptoms of angina or dyspnea, age ≥ 75 years, hemoglobin < 12 g/dl, vascular surgery, and emergency surgery. This study compares the performance of this new index among emergency and elective surgeries. METHODS AND RESULTS: The study population consisted of 1,167,414 non-cardiac surgeries registered in the American College of Surgeons National Surgical Quality Improvement Program database (153,715 were emergency and 1,013,699 were elective). Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or >3 depending on the number of data elements s/he has. The outcome measure (death, myocardial infarction, or stroke at 30 days after surgery) was higher in emergency than elective surgeries (7.0 % vs 1.4 %, p < 0.0001). The AUB-HAS2 index was able to stratify risk in both types of surgeries with a gradual increase in risk as the score increased (p < 0.0001). The discriminatory power of the AUB-HAS2 index, measured by the area under the receiver operator characteristic curves, was good and similar in the two types of surgeries (0.804 for emergency vs 0.791 for elective surgeries). CONCLUSION: The AUB-HAS2 index is a versatile tool that can effectively and equally stratify risk in both emergency and elective surgeries with a good discriminatory power.

The effect of a bundle intervention for ambulatory otorhinolaryngology procedures on same-day case cancellation rate and associated costs.

Cancellations within 24 h of planned elective surgical procedures reduce operating theatre efficiency, add unnecessary costs and negatively affect patient experience. We implemented a bundle intervention that aimed to reduce same-day case cancellations. This consisted of communication tools to improve patient engagement and new screening instruments (automated estimation of ASA physical status and case cancellation risk score plus four screening questions) to identify patients in advance (ideally before case booking) who needed comprehensive pre-operative risk stratification. We studied patients scheduled for ambulatory surgery with the otorhinolaryngology service at a single centre from April 2021 to December 2022. Multivariable logistic regression and interrupted time-series analyses were used to analyse the effects of this intervention on case cancellations within 24 h and costs. We analysed 1548 consecutive scheduled cases. Cancellation within 24 h occurred in 114 of 929 (12.3%) cases pre-intervention and 52 of 619 (8.4%) cases post-intervention. The cancellation rate decreased by 2.7% (95%CI 1.6-3.7%, p < 0.01) during the first month, followed by a monthly decrease of 0.2% (95%CI 0.1-0.4%, p < 0.01). This resulted in an estimated $150,200 (£118,755; €138,370) or 35.3% cost saving (p < 0.01). Median (IQR [range]) number of days between case scheduling and day of surgery decreased from 34 (21-61 [0-288]) pre-intervention to 31 (20-51 [1-250]) post-intervention (p < 0.01). Patient engagement via the electronic health record patient portal or text messaging increased from 75.9% at baseline to 90.8% (p < 0.01) post-intervention. The primary reason for case cancellation was patients' missed appointment on the day of surgery, which decreased from 7.2% pre-intervention to 4.5% post-intervention (p = 0.03). An anaesthetist-driven, clinical informatics-based bundle intervention decreases same-day case cancellation rate and associated costs in patients scheduled for ambulatory otorhinolaryngology surgery.

Case cancellations and associated factors on the day of surgery in hospitals of Wolaita Zone, South Ethiopia.

BACKGROUND: Cancellations of elective surgery cases are frequent and have significant negative consequences. It causes wasting of valuable resources, patient unhappiness, and psychological stress of patients. Despite this, little is known about the case cancellation and associated factors on the day of surgery in Ethiopia, particularly in the study area. OBJECTIVE: This study aimed to assess the magnitude of case cancellation and associated factors on the day of surgery in hospitals in Wolaita zone, South Ethiopia, from May 17 to June 17, 2023. METHODS: A hospital-based cross-sectional study involving 322 patients was conducted at Wolaita Sodo Zone, South Ethiopia. All elective surgical cases scheduled during the study period were included. The entire number of participants was selected using a systematic random sampling process. Epidata V.3 was used to enter data, and SPSS V.25 was used to analyze it. Binary logistic regression was used to check for a possible association. P-values < 0.05 and 95% CI were used on multi-variable analysis as the threshold for the significant statistical association. RESULT: A total of 313 study participants were scheduled for elective surgical procedures during the study period and gave a response rate of 97.2%. The mean (± SD) age of the study participants was 39.18 (± 10.64) years. The two-third of patients, 53(64%) were rural residents, and more than half (178, or 55.3%) of the participants were female. This finding showed that the case cancellation was 22.4% (95% CI: 19.3 -25.9%). Among the total canceled cases, 49(58.3%) were males. Variables like rural residence (AOR = 3.48 95% CI: 1.22-9.95), Lack of lab result (AOR = 2.33, 95%CI:1.20-4.51), ophthalmology dept. (AOR = 2.53 95% CI:1.52-4.49), HTN (AOR = 2.53, 95% CI:1.52-4.49), patient refusal (AOR = 3.01 95% CI:1.22-5.05), and age b/n 31 and 43 (AOR = 1.50, 95% CI:1.02-2.01) were significantly associated factors with cancellation of elective surgical cases. CONCLUSION: In this study schedule of case cancellation was high. The contributing factors of case cancellation were rural residence, Lack of lab results, ophthalmology dept, HTN, patient refusal, and age. To decrease unnecessary cancellations and increase cost efficiency, hospital administration and medical staff must plan ahead carefully, communicate effectively, and make efficient use of hospital resources.

The diagnostic accuracy of preoperative perfusion index as a predictor of postspinal anesthesia hypotension in parturients undergoing cesarean delivery: A prospective non-blinded observational study.

Background and Objectives: Spinal anesthesia is the technique of choice for elective cesarean section with a prominent side effect of postspinal anesthesia hypotension (PSH). This needs an early prediction to avoid feto-maternal complication. This study aimed to assess the diagnostic accuracy of perfusion index (PI) and inferior vena cava collapsibility index (IVCCI) in the prediction of PSH. Material and Methods: Thirty parturients of American Society of Anesthesiologists Physical Status (ASA-PS) 1 and two undergoing cesarean delivery participated in the study. IVCCI, PI, baseline systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR) were noted in the preoperative period. The fall of MBP by 20% from baseline or below 65 mm Hg was considered PSH. After spinal anesthesia, SBP, DBP, MBP, and HR were noted again for diagnosing PSH. Results: It did not show any statistical difference when comparing the PI between the PSH and non-PSH groups in both the PSH definition groups. IVCCI was significantly higher when PSH was considered MBP <65 mm Hg (P = 0.01). However, IVCCI was found to be statistically insignificant if PSH was considered a 20% reduction in baseline MBP. The correlation matrix between IVCCI and PI showed Pearson's r-value of 0.525, indicating a substantial relationship between the two (P = 0.003). Multivariate logistic regression analysis had shown that neither IVCCI nor PI was a good predictor of PSH in parturients for both definition groups for PSH. Conclusion: Although there is a modest correlation between PI and IVCCI, both cannot be used to predict postspinal hypotension in parturients undergoing elective lower-segment cesarean section (LSCS).

Shared Decision Making in Hallux Valgus Surgery: A Prospective Observational Study.

Patient-physician communication has the potential to improve outcomes and satisfaction through the shared decision-making process (SDM). This study aims to assess the relationship between perception of SDM and demographic, clinical, and patient-reported outcomes in patients undergoing Hallux Valgus (HV) correction. A prospective analysis of 306 patients scheduled for HV surgery was completed. The CollaboRATE score was used to measure SDM. Multivariable linear regression model was used to assess whether SDM scores were associated with preoperative characteristics or postoperative outcome scores. The mean CollaboRATE score was 2.9 (SD 0.9) and did not differ by age, socioeconomic status, or sex. Lower CollaboRATE scores were associated with more symptoms of depression, lower socioeconomic status, and lower general health scores (p-value < 0.05). There was no association between SDM scores and postoperative outcome scores. In this study, patients with depressive symptoms and lower socioeconomic status had worse perceptions of SDM. There was no difference in postoperative outcomes among participants based on SDM scores. Level of Evidence: Level III, prospective observational study.

Assessing patterns of delirium symptoms reveals a novel subtype among elective surgical patients with postoperative delirium.

OBJECTIVES: Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM-5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). METHODS: Data were from five independent study cohorts (N = 1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre- and post-surgery. Latent class analyses of CAM data from the first 2 days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. RESULTS: The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. CONCLUSIONS: Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium.

Population pharmacokinetic/pharmacodynamic modeling and exposure-response analysis of ciprofol in the induction and maintenance of general anesthesia in patients undergoing elective surgery: A prospective dose optimization study.

AIM: This study aimed to establish a population pharmacokinetic and pharmacodynamic (PK-PD) model to explore the optimal maintenance dose and appropriate starting time of maintenance dose after induction of ciprofol and investigate the efficacy and safety of ciprofol for general anesthesia induction and maintenance in patients undergoing elective surgery. METHOD: A total of 334 subjects with 3092 concentration measurements from nine clinical trials and 115 subjects with 5640 bispectral index (BIS) measurements from two clinical trials were used in the population PK-PD analysis. Exposure-response relationships for both efficacy endpoints (duration of anesthesia successful induction, time to recovery from anesthesia, time to respiratory recovery, and time from discontinuation to the 1st/3rd consecutive Aldrete score ≥ 9) and safety variables (hypotension, bradycardia, and injection site pain) were evaluated based on the data gathered from 115 subjects in two clinical trials. RESULT: Ciprofol pharmacokinetics (PK) were adequately described by a three-compartment model with first-order elimination from the central compartment and redistribution from the deep and shallow peripheral compartments. An inhibitory sigmoidal Emax model best described the relationship between ciprofol effect-site concentrations and BIS measurements. Body weight, age, sex, blood sampling site, and study type (short-term infusion vs long-term infusion) were identified as statistically significant covariates on the PK of ciprofol. No covariates were found to have a significant effect on the pharmacodynamic (PD) parameters. The PK-PD simulation results showed that the optimal maintenance dose was 0.8 mg/kg/h and the appropriate time to start the maintenance dose was 4-5 mins after the induction dose of ciprofol. Within the exposure range of this study, no meaningful correlations between ciprofol exposures and efficacy or safety endpoints were observed. CONCLUSION: A population PK-PD model was successfully developed to describe the ciprofol PK and BIS changes. Efficacy was consistent across the exposure range with a well-tolerated safety profile indicating no maintenance dose adjustment is required for patients undergoing elective surgery.

Driving Factors of Recommending a Hand Surgery Clinic After Surgery.

PURPOSE: Since a patient's recommendation of a clinic to others is an important indicator of patient experience, more insight is needed into the underlying factors that motivate such recommendations. This retrospective cohort study assessed the relative contribution of the following: (1) patient-related characteristics, (2) treatment outcome, (3) satisfaction with treatment outcome, and (4) patients' experience with the process of care to patients' recommendation of a specific clinic after elective surgery. METHODS: Patients of specialized outpatient hand surgery clinics (N = 6,895) reported the likelihood of recommending the clinic to friends or family 3-5 months after surgery by filling in the Net Promoter Score. Potential predictors of the Net Promoter Score were preoperative patient characteristics, patient-reported treatment outcomes, satisfaction with treatment outcome, and experience with several health care delivery domains. Linear regression analyses were used to examine the contribution of the predictors. RESULTS: Mean age of the patients was 53 (SD, 14) years, 62.5% were women, and 62.5% were employed. Preoperative patient characteristics explained 1% of the variance in clinic recommendations. An additional 6% was explained by the treatment outcome, 21.6% by satisfaction with treatment outcome, and 33.8% by patients' experience with care delivery (total explained variance was 62.3%). The strongest independent predictors of clinic recommendations were positive experiences with the quality of the facilities and the communication skills of the physician. CONCLUSIONS: Patient recommendations are more strongly driven by patients' experience with care delivery than by treatment outcome and patient characteristics. CLINICAL RELEVANCE: In elective surgery, improving patient experiences is pivotal in boosting patient recommendation of the clinic.

Alarmins and Related Molecules in Elective Surgery.

Surgery is associated with alterations of alarmins' and related molecules' levels. The aim of this study was to investigate which biomarkers are most involved in surgery. The studied group consisted of 58 patients with inguinal or umbilical hernia or cholecystolithiasis and 21 healthy controls for compa-rison. We also added seven acute patients with appendicitis, cholecystitis and incarcerated hernia. Serum concentrations of soluble receptor of advanced glycation end-products (sRAGE), extracellular newly identified receptor for advanced glycation end-products binding protein (EN-RAGE), calprotectin, high mobility group box 1 (HMGB1) and interleukin 6 (IL-6) were analysed by ELISA before and after surgery. Preoperative concentrations of calprotectin were significantly decreased while concentrations of sRAGE were significantly increased in patients compared to controls; the concentrations of EN-RAGE and HMGB1 did not differ significantly. IL-6 levels were undetectable in elective patients preoperatively and in controls. Postoperatively, there was a significant increase of EN-RAGE, calprotectin, HMGB1, and IL-6 and a significant decrease of sRAGE compared to preoperative levels. In acute patients, all tested molecules except for sRAGE were significantly increased preoperatively, and sRAGE was significantly decreased. In contrast, after surgery, we could observe a further increase in IL-6; the other biomarkers did not differ significantly. We can conclude that the concentrations of all tested biomarkers are significantly influenced by elective surgery. The postoperative levels of all tested molecules increase except for sRAGE, whose level is significantly decreased after surgery. In acute states, these molecules are already increased, and the influence of surgery is, apart from IL-6, insignificant.