Post- versus intra-operative implant for breast cancer interstitial brachytherapy: How to choose?

Purpose: Breast brachytherapy (BB) represents an important radiation therapy modality in modern breast cancer treatments. Currently, BB is mainly used for accelerated partial breast irradiation (APBI), local boost after whole breast radiation therapy (WBRT), and as salvage re-irradiation after second lumpectomy (APBrl). Two multi-catheter interstitial brachytherapy (MIB) techniques can be offered: intra-operative (IOB) and post-operative (POB) brachytherapy. The aim of this article was to summarize current available data on these two different brachytherapy approaches for breast cancer. Material and methods: A literature search was performed, and different experiences published by BB expert teams were analyzed and compared. These two different brachytherapy approaches for breast cancer have also been presented and discussed during meetings of the GEC-ESTRO BCWG. In addition, expert recommendations were defined. Results: A comprehensive description and practical comparison of both the techniques, i.e., IOB and POB, considering the latest available published data were presented. Different technical, logistic, and clinical aspects of both the methods were thoroughly examined and analyzed. This detailed comparison of the two breast brachytherapy techniques was supported by scientific data from extensive experience of experts, facilitating an objective analysis that, to our knowledge, has not been previously published. Conclusions: Based on the comprehensive analysis of both the brachytherapy techniques available, this article serves as a valuable resource to guide breast teams in selecting the optimal BB technique (POB or IOB), considering hospital environment, multi-disciplinary collaboration, and patient logistics.

Spatial and temporal properties of intra-operatively recorded spikes and high frequency oscillations in focal cortical dysplasia.

OBJECTIVE: Focal cortical dysplasias (FCD) are characterized by distinct interictal spike patterns and high frequency oscillations (HFOs; ripples: 80-250 Hz; fast ripples: 250-500 Hz) in the intra-operative electrocorticogram (ioECoG). We studied the temporal relation between intra-operative spikes and HFOs and their relation to resected tissue in people with FCD with a favorable outcome. METHODS: We included patients who underwent ioECoG-tailored epilepsy surgery with pathology confirmed FCD and long-term Engel 1A outcome. Spikes and HFOs were automatically detected and visually checked in 1-minute pre-resection-ioECoG. Channels covering resected and non-resected tissue were compared using a logistic mixed model, assessing event numbers, co-occurrence ratios, and time-based properties. RESULTS: We found pre-resection spikes, ripples in respectively 21 and 20 out of 22 patients. Channels covering resected tissue showed high numbers of spikes and HFOs, and high ratios of co-occurring events. Spikes, especially with ripples, have a relatively sharp rising flank with a long descending flank and early ripple onset over resected tissue. CONCLUSIONS: A combined analysis of event numbers, ratios, and temporal relationships between spikes and HFOs may aid identifying epileptic tissue in epilepsy surgery. SIGNIFICANCE: This study shows a promising method for clinically relevant properties of events, closely associated with FCD.

Incidence of intraoperative hypotension and its factors among adult traumatic head injury patients in comprehensive specialized hospitals, Northwest Ethiopia: a multicenter observational study.

INTRODUCTION: Traumatic head injury (THI) poses a significant global public health burden, often contributing to mortality and disability. Intraoperative hypotension (IH) during emergency neurosurgery for THI can adversely affect perioperative outcomes, and understanding associated risk factors is essential for prevention. METHOD: A multi-center observational study was conducted from February 10 to June 30, 2022. A simple random sampling technique was used to select the study participants. Patient data were analyzed using bivariate and multivariate logistic regression to identify significant factors associated with intraoperative hypotension (IH). Odds ratios with 95% confidence intervals were used to show the strength of association, and P value < 0.05 was considered as statistically significant. RESULT: The incidence of intra-operative hypotension was 46.41% with 95%CI (39.2,53.6). The factors were duration of anesthesia ≥ 135 min with AOR: 4.25, 95% CI (1.004,17.98), severe GCS score with AOR: 7.23, 95% CI (1.098,47.67), intracranial hematoma size ≥ 15 mm with AOR: 7.69, 95% CI (1.18,50.05), and no pupillary abnormality with AOR: 0.061, 95% CI (0.005,0.732). CONCLUSION AND RECOMMENDATION: The incidence of intraoperative hypotension was considerably high. The duration of anesthesia, GCS score, hematoma size, and pupillary abnormalities were associated. The high incidence of IH underscores the need for careful preoperative neurological assessment, utilizing CT findings, vigilance for IH in patients at risk, and proactive management of IH during surgery. Further research should investigate specific mitigation strategies.

Pre-emptive paracetamol reduces intra-operative opioid use in patients undergoing day-case oncologic breast surgery.

Minimization of intra-operative opioid use is an area of ongoing research interest with several potential benefits to the patient. Pre-emptive analgesia, defined as the administration of an analgesic before surgery to prevent establishment of central sensitization of pain, is one avenue that has been explored to achieve this. A retrospective observational study was undertaken to examine the effect of pre-emptive paracetamol on intra-operative opioid requirements. The medical and operative data of 156 patients who underwent day-case wide local excision and sentinel lymph node biopsy with and without regional block surgery at our center between October 2019 and May 2022 was carried out. Data were collected on demographics, total intra-operative and immediate post-operative opioid consumption. 57 patients did not receive pre-emptive paracetamol while 90 did. Baseline characteristics were similar. Our results showed a statistically significant reduction in morphine (p <0.029) and remifentanil (p <0.007) consumption in patients who received a regional block and pre-emptive paracetamol. Those who did not receive a regional block and were given pre-emptive paracetamol had a decrease in OxyNorm (p <0.022) requirements. A combination of general anesthesia (GA), regional block and pre-emptive paracetamol reduced intra-operative consumption of Fentanyl, OxyNorm, diclofenac, dexketoprofen, and clonidine (P <0.001) when compared to just GA alone. Use of pre-emptive paracetamol in reduction of intra-operative opioid requirements showed promising results but larger studies may strengthen the evidence for this association. A multimodal analgesic approach that utilizes pre-emptive paracetamol can be a viable method to decrease intra-operative of analgesic requirements.

A systematic review of cardiac surgery clinical prediction models that include intra-operative variables.

BACKGROUND: Most cardiac surgery clinical prediction models (CPMs) are developed using pre-operative variables to predict post-operative outcomes. Some CPMs are developed with intra-operative variables, but none are widely used. The objective of this systematic review was to identify CPMs with intra-operative variables that predict short-term outcomes following adult cardiac surgery. METHODS: Ovid MEDLINE and EMBASE databases were searched from inception to December 2022, for studies developing a CPM with at least one intra-operative variable. Data were extracted using a critical appraisal framework and bias assessment tool. Model performance was analysed using discrimination and calibration measures. RESULTS: A total of 24 models were identified. Frequent predicted outcomes were acute kidney injury (9/24 studies) and peri-operative mortality (6/24 studies). Frequent pre-operative variables were age (18/24 studies) and creatinine/eGFR (18/24 studies). Common intra-operative variables were cardiopulmonary bypass time (16/24 studies) and transfusion (13/24 studies). Model discrimination was acceptable for all internally validated models (AUC 0.69-0.91). Calibration was poor (15/24 studies) or unreported (8/24 studies). Most CPMs were at a high or indeterminate risk of bias (23/24 models). The added value of intra-operative variables was assessed in six studies with statistically significantly improved discrimination demonstrated in two. CONCLUSION: Weak reporting and methodological limitations may restrict wider applicability and adoption of existing CPMs that include intra-operative variables. There is some evidence that CPM discrimination is improved with the addition of intra-operative variables. Further work is required to understand the role of intra-operative CPMs in the management of cardiac surgery patients.

Preventing Shift from Pneumocephalus During Deep Brain Stimulation Surgery: Don't Give Up the 'Fork in the Brain'.

Clinical vignette: We present the case of a patient who developed intra-operative pneumocephalus during left globus pallidus internus deep brain stimulation (DBS) placement for Parkinson's disease (PD). Microelectrode recording (MER) revealed that we were anterior and lateral to the intended target. Clinical dilemma: Clinically, we suspected brain shift from pneumocephalus. Removal of the guide-tube for readjustment of the brain target would have resulted in the introduction of movement resulting from brain shift and from displacement from the planned trajectory. Clinical solution: We elected to leave the guide-tube cannula in place and to pass the final DBS lead into a channel that was located posterior-medially from the center microelectrode pass. Gap in knowledge: Surgical techniques which can be employed to minimize brain shift in the operating room setting are critical for reduction in variation of the final DBS lead placement. Pneumocephalus after dural opening is one potential cause of brain shift. The recognition that the removal of a guide-tube cannula could worsen brain shift creates an opportunity for an intraoperative team to maintain the advantage of the 'fork' in the brain provided by the initial procedure's requirement of guide-tube placement.

Definition, Frequency and Risk Factors for Intra-Operative Spinal Cord Injury: A Knowledge Synthesis.

STUDY DESIGN: Mixed-methods approach. OBJECTIVES: Intra-operative spinal cord injury (ISCI) is a devastating complication of spinal surgery. Presently, a uniform definition for ISCI does not exist. Consequently, the reported frequency of ISCI and important risk factors vary in the existing literature. To address these gaps in knowledge, a mixed-methods knowledge synthesis was undertaken. METHODS: A scoping review was conducted to review the definitions used for ISCI and to ascertain the frequency of ISCI. The definition of ISCI underwent formal review, revision and voting by the Guidelines Development Group (GDG). A systematic review of the literature was conducted to determine the risk factors for ISCI. Based on this systematic review and GDG input, a table was created to summarize the factors deemed to increase the risk for ISCI. All reviews were done according to PRISMA standards and were registered on PROSPERO. RESULTS: The frequency of ISCI ranged from 0 to 61%. Older age, male sex, cardiovascular disease including hypertension, severe myelopathy, blood loss, requirement for osteotomy, coronal deformity angular ratio, and curve magnitude were associated with an increased risk of ISCI. Better pre-operative neurological status and use of intra-operative neuromonitoring (IONM) were associated with a decreased risk of ISCI. The risk factors for ISCI included a rigid thoracic curve with high deformity angular ratio, revision congenital deformity with significant cord compression and myelopathy, extrinsic intradural or extradural lesions with cord compression and myelopathy, intramedullary spinal cord tumor, unstable spine fractures (bilateral facet dislocation and disc herniation), extension distraction injury with ankylosing spondylitis, ossification of posterior longitudinal ligament (OPLL) with severe cord compression, and moderate to severe myelopathy. CONCLUSIONS: ISCI has been defined as "a new or worsening neurological deficit attributable to spinal cord dysfunction during spine surgery that is diagnosed intra-operatively via neurophysiologic monitoring or by an intraoperative wake-up test, or immediately post-operatively based on clinical assessment". This paper defines clinical and imaging factors which increase the risk for ISCI and that could assist clinicians in decision making.

AO Spine/Praxis Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury: An Introduction to a Focus Issue.

STUDY DESIGN: Narrative overview and summary. OBJECTIVES: The objective of this introductory manuscript is to provide an overview of the effort that was undertaken to establish clinical practice guidelines for a number of important topics in spinal cord injury (SCI). These topics included: 1. The role and timing of surgical decompression after acute traumatic SCI; 2. The hemodynamic management of acute traumatic SCI; and 3. The definition, diagnosis, and management of intra-operative SCI. Here, we introduce the rationale for the guidelines, the methodology utilized, and summarize how the topics are addressed within various manuscripts of this Focus Issue. METHODS: The key clinical questions were defined using the PICO format for treatment reviews (patient; intervention; comparison; outcomes) or PPO format (patient, prognostic factor, outcomes) for risk factor review. Multi-disciplinary, international guideline development groups (GDGs) were established to evaluate and collate the available evidence in a rigorous, systematic manner, followed by a review of systematically obtained evidence within the framework of the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria and application of the Evidence to Decision process. Consensus meetings, using a modified Delphi approach, were held with the multidisciplinary, international GDGs using online video-conferencing technology and anonymous voting to develop the final recommendations for each of the topics addressed. All systematic review protocols followed PRISMA standards and were registered on PROSPERO; all potential conflicts were vetted in an open and transparent manner. The funders (AO Spine and Praxis Spinal Cord Institute) had no influence over editorial content or the guidelines process). RESULTS: Updated guidelines were established for the timing of surgical decompression after acute SCI, with surgical decompression within 24 hours of injury now "recommended" as a treatment option. Updated guidelines were also established for hemodynamic management, with an expanded target range for mean arterial pressure (MAP) of 75-80 to 90-95 mmHg for between 3 to 7 days post-injury now "suggested" as a treatment option. The available literature mandated scoping and systematic reviews on the topic of intra-operative SCI, and this resulted in manuscripts to address the definition, frequency, and risk factors, to define the role of intra-operative neuromonitoring, and to suggest an evidence-based care pathway for management. CONCLUSION: A rigorous process following GRADE standards was undertaken to review the available evidence and establish guideline recommendations around the role and timing of surgery in acute SCI, optimal hemodynamic management of acute SCI and the prevention, diagnosis and management of intraoperative SCI. This effort also identified key knowledge gaps and future directions for study, which will serve to refine these recommendations in the future.

Intradural lumbar disc herniation with cauda equina syndrome: Case report and recent advances.

Introduction: Intradural lumbar disc herniations (IDDH) are unusual and represent less than 0.3% of all lumbar disc herniations. They have a higher incidence of cauda equina syndrome. The possibility of intradural disc herniation is often missed on Magnetic Resonance Imaging (MRI) and during surgery if the size of the disc prolapse is inconsistent with the compression seen on the MRI. In such situations, the possibility of IDDH should be suspected. Research question: How to diagnose intradural disc herniation pre-operatively? Surgical techniques if the intra-dural disc herniation is encountered intra-operatively. Material and methods: In this article, we describe a case report of an intradural disc herniation (IDDH) causing cauda equina syndrome at the L4-5 level and who underwent surgical decompression. This case report highlights that by doing a dorsal durotomy and by using microsurgical techniques, excision of the intradural disc fragment can be achieved without any rootlet injury. Results: At a 2-year follow-up, the patient has recovered completely from motor weakness and bowel and bladder incontinence. Discussion and conclusion: Though uncommon intra-dural disc herniation can be diagnosed pre-operatively by its characteristic signs or by using newer techniques like 3-dimensional constructive interference in steady state (CISS) MRI. Intra-operative ultrasonography (IOUS) is a handy tool to localise and diagnose intra-dural disc herniation intra-operatively and its use is encouraged. Timely intervention can lead to acceptable outcomes even with cauda equina syndrome.

Diagnostic utility of intraoperative squash smear cytology of Intra-cranial lesions in a resource limited setup of central India.

Introduction: Intraoperative squash smear cytology is a useful diagnostic tool in case of CNS lesions. In resource poor countries where frozen section is unavailable, cytology is the mainstay method in giving a rapid intraoperative diagnosis which helps Surgeons regarding the extent of excision. The current study aims to assess the feasibility and accuracy of intraoperative squash cytology in evaluation of CNS tumors. Definitive diagnosis is confirmed by histopathological examination. Materials and methods: This retrospective observational study was carried out at Department of Neuropathology. All patients diagnosed with space occupying lesion (SOL) in CNS were enrolled in the study. Intra-operative cytological diagnosis was compared to histopathological diagnosis. WHO classification of CNS tumors 2021 was used to classify tumors. Results: Total seventy patients with intracranial SOLs were enrolled in this study who were operated for the same and their specimens were examined. Two samples were found to be inadequate and not included in final analysis. Mean age was 38.8 ± 17.85 (SD). Male-female ratio was 1.5:1 with 41 (60.3%) males and 27 (39.7%) females. 58 had neoplastic and rest 10 had non-neoplastic lesions. Complete concordance was achieved in 61 cases (Diagnostic Accuracy-88.2%). 3 (4.4%) cases showed partial concordance and 4 (5.9%) were discordant. For detection of malignant lesions through squash smear cytology overall Sensitivity was 73.9%, Specificity-97.8%, Positive Predictive Value-94.4% and Negative Predictive Value-88%. Conclusions: Squash smear cytology is a simple, rapid and cost-effective method relying solely on the expertise of pathologist. High diagnostic accuracy can be achieved with squash cytology by taking clinical and radiological findings into consideration.

Cystic Echinococcosis of the Liver: Correlation Between Intra-Operative Ultrasound and Pre-Operative Imaging.

Background: Imaging plays an essential role in the management of hepatic hydatid cysts (HCE). The objective of our study was to determine the correlation between pre-operative ultrasound, computed tomography (CT), and intra-operative ultrasound (IOUS) in studying the characteristics and complications of HCE. Patients and Methods: This was a prospective, descriptive, and analytical study conducted in the General Surgery Department of Habib Bourguiba Hospital in Sfax. The study included patients with HCE who underwent conservative surgery between April 2017 and June 2022. Results: We enrolled 49 patients with 94 cysts. At the end of our study, IOUS allowed for better detection of HCE (98.8%) regardless of the number of cysts per patient. IOUS and CT were accurate in studying the location of cysts (κ = 1), whereas pre-operative abdominal ultrasound was less efficient (κ = 0.870). IOUS was the best examination for detecting exocysts (κ = 0.961), studying daughter cysts (κ = 0.823), and exploring vascular relations, but it was less effective (κ = 0.523) in detecting calcifications. Regarding classifications, ultrasound and CT had similar results. However, IOUS was most reliable in differentiating between CE3b and CE4 types (κ = 0.653). Ultrasound, CT, and IOUS were not sensitive in detecting latent HCE suppurations and cystobiliary fistulas. Conclusions: Performing IOUS is essential to prevent recurrences and reduce post-operative morbidity.

The effect of propofol on effective brain networks.

OBJECTIVE: We compared the effective networks derived from Single Pulse Electrical Stimulation (SPES) in intracranial electrocorticography (ECoG) of awake epilepsy patients and while under general propofol-anesthesia to investigate the effect of propofol on these brain networks. METHODS: We included nine patients who underwent ECoG for epilepsy surgery evaluation. We performed SPES when the patient was awake (SPES-clinical) and repeated this under propofol-anesthesia during the surgery in which the ECoG grids were removed (SPES-propofol). We detected the cortico-cortical evoked potentials (CCEPs) with an automatic detector. We constructed two effective networks derived from SPES-clinical and SPES-propofol. We compared three network measures (indegree, outdegree and betweenness centrality), the N1-peak-latency and amplitude of CCEPs between the two effective networks. RESULTS: Fewer CCEPs were observed during SPES-propofol (median: 6.0, range: 0-29) compared to SPES-clinical (median: 10.0, range: 0-36). We found a significant correlation for the indegree, outdegree and betweenness centrality between SPES-clinical and SPES-propofol (respectively rs = 0.77, rs = 0.70, rs = 0.55, p < 0.001). The median N1-peak-latency increased from 22.0 ms during SPES-clinical to 26.4 ms during SPES-propofol. CONCLUSIONS: Our findings suggest that the number of effective network connections decreases, but network measures are only marginally affected. SIGNIFICANCE: The primary network topology is preserved under propofol.

Risk factors of high fluid absorption in patients treated with mini-PCNL: a single-center prospective study.

BACKGROUND: The factors influencing fluid absorption in mini-percutaneous nephrolithotripsy (mini-PCNL) are still unknown. We aim to investigate the factors that influence irrigation fluid absorption during mini-PCNL. METHODS: A total of 94 patients who underwent mini-PCNL were included in this prospective study. The endoscopic surgical monitoring system (ESMS) was used to measure the volume of irrigation fluid absorbed during the procedure. Irrigating time, the total volume of irrigation fluid, stone size, S.T.O.N.E. score, hemoglobin, electrolyte levels, and postoperative complications were recorded. RESULTS: A significant correlation was observed between fluid absorption and the presence of postoperative fever, and based on this phenomenon, patients were divided into low and high fluid absorption groups. The serum creatinine level in the high fluid absorption group was significantly high (7 vs. 16.5, p = 0.02). Significant differences were observed between the low and high fluid absorption groups in terms of mean stone size (21.70 mm vs. 26.78 mm), presence of stone burden ≥ 800 mm2 (4% vs. 23%), S.T.O.N.E. score > 8 (4% vs. 38%), the fluid used > 18,596 ml (19% vs. 78%), irrigation time (55.61 min vs. 91.28 min), and perfusion rate (24% vs. 45%) (all p < 0.05). The rates of postoperative fever and SIRS in the high fluid absorption group were significantly high (p < 0.05). CONCLUSIONS: Mean stone size, presence of stone burden ≥ 800 mm2, S.T.O.N.E. score > 8, the fluid used > 18596 mL, irrigation time, and perfusion rate are risk factors of intraoperative fluid absorption in mini-PCNL.

Efficacy of prophylactic use of intraoperative vancomycin powder in preventing surgical site infection in neurological surgeries in Irrua, Nigeria: A randomized controlled study.

PURPOSE: The objective was to determine the efficacy of intraoperative vancomycin powder in preventing SSIs in neurological surgeries. METHODS: A prospective randomized controlled study of patients who had clean cranial and non-implant spine surgeries at the Irrua Specialist Teaching Hospital, Irrua, Nigeria from February 1, 2021 to January 31, 2022. Patients were randomized into two groups. Group A patients had prophylactic intraoperative vancomycin powder applied to the surgical bed before wound closure while group B patients did not. Patients in both groups were followed up for 30 days post-operatively for evidence of SSI. The occurrence of SSIs was determined using clinical and laboratory parameters. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were recorded. Data was analyzed using Statistical Package for Scientific Solution (SPSS) version 23 software. RESULTS: Forty-two patients were randomized into 2 groups of 21 patients each. The age range of the patients was 20 to 80 years. The majority of the patients were males (32 out of 42). The mean age of patients in group A was 48.05 ± 17.03 years, while group B had a mean age of 45.95 ± 19.14 years. The mean Body Mass Index of patients in groups A and B were 23.92 ± 5.21 and 23.21 ± 3.99 respectively. Seven out of 21 patients (33.3 %) in the control group ( group B) had superficial SSIs while no patient in the experimental group had SSI, p-value < 0.05. The organisms cultured were Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus. CONCLUSION: Intraoperative vancomycin powder was effective in reducing the rate of SSIs following neurological surgeries and without adverse drug reactions.

Custom-made Glenoid Baseplate and Intra-Operative Navigation in Complex Revision Reverse Shoulder Arthroplasty: A Case Report.

Prosthetic instability is one of the most challenging complications to manage when considering reverse shoulder arthroplasty (RSA). Additional tools are available to improve accuracy in planning and execution of arthroplasties, such as 3-dimensional (3D) virtual planning based on computer tomography (CT) scan and intra-operative navigation. We report a case of an 84-year-old male treated for RSA prosthetic instability combined with severe glenoid deformity and bone loss, and subclinical periprosthetic joint infection (PJI). The definitive surgery consisted in implanting a customized metaglene component realized on the basis of the bone defect detected in the 3D-CT scan and implanted with the aid of computer-assisted intra-operative navigation. The patient was periodically followed-up for a year with clinical and radiological evaluations with the absence of further prosthetic dislocations nor PJI, a good overall satisfaction, a satisfying range of motion, and acceptable functional scores (American Shoulder and Elbow Surgeons Score 62, Constant-Murley Score 36). This is the first description, to our knowledge, of a customized glenoid baseplate implanted with the aid of intraoperative navigation. The combined use of 3D-CT planning and intra-operative computer-assisted navigation allows to manage complex cases of prosthetic revision surgery even where extensive bone defects are present.

Second-trimester dilatation and evacuation: Comparison of routine intraoperative ultrasonography versus problem-based intraoperative ultrasonography in reducing procedure-related complications: A pre-post study.

OBJECTIVE: To investigate whether routine intraoperative ultrasonographic guidance during second-trimester dilatation and evacuation (D&E) reduces procedure-related complications in an Ethiopian setting. METHODS: We conducted a pre-post study on routine ultrasonography during second-trimester D&E at St. Paul's Hospital Millennium Medical College (Ethiopia). Second-trimester D&E cases that were managed at the hospital between 2017 and 2022 were retrospectively analyzed by grouping them into an intervention group (using routine ultrasound intraoperatively for all cases) and a non-intervention group (problem-based intraoperative use of ultrasound, where ultrasound was used in problem cases only). SPSS version 23 was used for analysis and simple descriptive statistics, χ2 test, multivariate regression analysis, and Fisher exact test were performed as appropriate. P values less than 0.05 and odds ratio with 95% CI were used to present the results' significance. RESULTS: A total of 242 second-trimester D&E cases were analyzed (84 cases managed under routine intraoperative ultrasound guidance and 158 cases managed with a problem-based intraoperative use of ultrasound). Compared with problem-based intraoperative use of ultrasound (using it only in selected cases), routine intraoperative ultrasound use was not associated with a decrease in D&E complications (adjusted odds ratio [aOR] 0.22, 95% confidence interval [CI] 0.04-1.16). The two factors associated with increased D&E procedure complications were advanced gestational age (aOR 13.52, 95% CI 1.86-98.52), and need for additional mechanical cervical dilatation during the D&E procedure (aOR 9.53, 95% CI 1.32-69.07). Provider experience, cervical preparation methods (laminaria vs Foley), and maternal age were not associated with occurrence of D&E complications. CONCLUSION: Our study does not support the preference of routine intraoperative ultrasound guidance over problem-based (in selected cases) intraoperative ultrasound use during the second-trimester D&E procedure. More research is needed to make a strong clinical recommendation on using routine intraoperative ultrasound guidance during all second-trimester D&E procedures.

The positional consistency between guidewire and cannulated or solid screw in robot-assisted spinal internal fixation surgery.

BACKGROUND: This study aimed to investigate the positional consistency between the guidewire and the screw in spinal internal fixation surgery. METHODS: This study involved 64 patients who underwent robot-assisted thoracic or lumbar pedicle screw fixation surgery. Guidewires were inserted with the assistance of the Tirobot. Either cannulated screws or solid screws were inserted. Guidewire and screw accuracy was measured using CT images based on the Gertzbein and Robbins scale. The positional consistency between guidewire and screw was evaluated based on the fused CT images, which could graphically and quantitatively demonstrate the consistency. The consistency was evaluated based on a grading system that considered the maximum distance and angulation between the centerline of the guidewire and the screw in the region of the pedicle. RESULTS: A total of 322 screws were placed including 206 cannulated ones and 116 solid ones. Based on the Gertzbein and Robbins scale, 97.5% of the guidewires were grade A, and 94.1% of the screws were grade A. Based on our guidewire-screw consistency scale, 85% in cannulated group, and 69.8% in solid group, were grade A. Both solid and cannulated screws may alter trajectory compared to the guidewires. The positional accuracy and guidewire-screw consistency in the solid screw group is significantly worse than that in the cannulated screw group. The cortical bone of the pedicle has a positive guide effect on either solid or cannulated screws. CONCLUSION: The pedicle screws may alter trajectory despite the guidance of the guidewires. Solid screws show worse positional accuracy and guidewire-screw consistency compared with cannulated screws. Trial registration The study was retrospectively registered and approved by our center's institutional review board.

Broad Responses and Attitudes to Having Music in Surgery (The BRAHMS Study): An Australia and Aotearoa New Zealand Perspective.

Background: Surgery is a stressful exercise, and the experience of occupational stress may have impacts on surgical performance, and surgeon well-being. Music is played in operating theatres (OTs) throughout the world, and while it may improve surgical performance, and reduce clinician stress within the OT, concerns exist over its distracting and noise-creating properties. Methods: In this prospective observational study, between May to August 2022, Vascular, General and Paediatric surgeons and registrars in Australia and Aotearoa New Zealand (AoNZ) responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment. Binomial logistic regression and Chi squared tests of association were performed, accepting p < 0.05 as significant. Results: In this cohort of 120 surgeons, 45 % were vascular specialists, 30 % were female and 59 % were consultant surgeons. The most commonly preferred music genres were easy listening and pop. Over 75 % of surgeons enjoyed having music in their OTs with the majority reporting it improved their temperament, how mentally fatiguing a procedure felt and how anxious or stressed they felt. Vascular surgeons were more likely to believe music had a positive influence on communication than their general and paediatric surgery colleagues (p < 0.01). Registrars had significantly higher odds of believing music had a positive effect on their temperament, and how stressed and anxious they felt when operating, when compared to consultants (p < 0.05). Conclusions: This study provides a window into the surgeons' use of and attitudes towards intra-operative background music and its effect on stress and cognitive load in Australia and AoNZ. While overall, music is viewed positively by this cohort, there was some difference seen across specialties and level of experience. Further subjective and objective data in this field may provide useful information to guide hospital policy and inform pathways for clinician wellbeing.