External validation of the CARDOT score for predicting respiratory complications after thoracic surgery.

BACKGROUND: The CARDOT scores have been developed for prediction of respiratory complications after thoracic surgery. This study aimed to externally validate the CARDOT score and assess the predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) for postoperative respiratory complication. METHODS: A retrospective cohort study of consecutive thoracic surgical patients at a single tertiary hospital in northern Thailand was conducted. The development and validation datasets were collected between 2006 and 2012 and from 2015 to 2021, respectively. Six prespecified predictive factors were identified, and formed a predictive score, the CARDOT score (chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status, right-sided operation, duration of surgery, preoperative oxygen saturation on room air, thoracotomy), was calculated. The performance of the CARDOT score was evaluated in terms of discrimination by using the area under the receiver operating characteristic (AuROC) curve and calibration. RESULTS: There were 1086 and 1645 patients included in the development and validation datasets. The incidence of respiratory complications was 15.7% (171 of 1086) and 22.5% (370 of 1645) in the development and validation datasets, respectively. The CARDOT score had good discriminative ability for both the development and validation datasets (AuROC 0.789 (95% CI 0.753-0.827) and 0.758 (95% CI 0.730-0.787), respectively). The CARDOT score showed good calibration in both datasets. A high NLR (≥ 4.5) significantly increased the risk of respiratory complications after thoracic surgery (P < 0.001). The AuROC curve of the validation cohort increased to 0.775 (95% CI 0.750-0.800) when the score was combined with a high NLR. The AuROC of the CARDOT score with the NLR showed significantly greater discrimination power than that of the CARDOT score alone (P = 0.008). CONCLUSIONS: The CARDOT score showed a good discriminative performance in the external validation dataset. An addition of a high NLR significantly increases the predictive performance of CARDOT score. The utility of this score is valuable in settings with limited access to preoperative pulmonary function testing.

A Randomized Comparison of Effects of Budesonide Spray and K-Y Gel as an Endotracheal Tube Cuff Lubricant on Incidence of Postoperative Sore Throat.

PURPOSE: Postoperative sore throat (POST) is a frequent postoperative complication. Preinduction budesonide inhalation is effective in POST prevention. However, it requires inhaler equipment and patient cooperation. Budesonide spraying on the endotracheal (ETT) cuff is simple and can be performed on most patients requiring endotracheal intubation. This study aims to compare the effects of budesonide spray and K-Y gel as an ETT cuff lubricant on the incidence and severity of POST. DESIGN: Randomized and triple-blinded study. METHODS: One hundred patients undergoing elective noncardiac surgery were randomly allocated into the budesonide group (n = 50) and the K-Y gel group (n = 50). In the budesonide group, 200 mcg of budesonide was sprayed on the cuff of the ETT. For the K-Y gel group, the ETT cuff was lubricated with K-Y gel. A visual analog scale was used to assess the severity of POST at 2, 6, and 24 hours after surgery. Other complications of tracheal intubation and adverse effects of budesonide were also recorded. FINDINGS: Compared to the K-Y gel group, the budesonide group had a significantly lower overall incidence of POST (30% versus 54%, P = .032) and reduced the risk of POST by 24% (relative risk reduction = 24%, 95% CI, 5.23-42.77, P = .012) as well as the incidence of hoarseness (8.6% vs 34%, P = .001) and cough (0% vs 8%, P = 0.041). No incidence of drug-related side effects was reported in both groups. CONCLUSIONS: Spraying budesonide on the ETT cuff significantly reduces the incidence and severity of POST.

Effective Dose Range of Intrathecal Isobaric Bupivacaine to Achieve T5-T10 Sensory Block Heights for Elderly and Overweight Patients: An Observational Study.

Background and Objectives: The dose selection for isobaric bupivacaine determines the success of spinal anesthesia (SA). A dose higher than the optimal dose causes high SA, whereas an underdose leads to inadequate spread of cephalad. As it involves anatomical and physiological alterations, the dosing should be reduced with advancing age and body mass index values. Therefore, this study aimed to demonstrate the association between the isobaric bupivacaine dose and block height, and to determine the dose intervals of bupivacaine to achieve the T5-T10 sensory block with a low probability of high SA in elderly and overweight patients. Material and Methods: This retrospective observational study recruited 1079 adult patients who underwent SA with 0.5% isobaric bupivacaine from 2018 to 2021. The patients were divided into four categories: category 1 (age < 60, BMI < 25), category 2 (age < 60, BMI ≥ 25), category 3 (age ≥ 60, BMI < 25), and category 4 (age ≥ 60, BMI ≥ 25). The bupivacaine dose and sensory block height (classified into three levels: high (T1-T4), favorable (T5-T10), and low (T11-L2)) were recorded. Results: The sensory block level increased significantly with increasing doses of bupivacaine for patients in categories 1 and 2. The suggested dose ranges for the favorable block heights were 15-17 and 10.5-16 mg in patient categories 1-2 and 3-4, respectively. In these dose ranges, the probability range of high SA was 10-15%. Conclusions: The sensory block height following SA was associated with the bupivacaine dose in patients aged <60 years. Regardless of the BMI, the suggested dose ranges of 0.5% isobaric bupivacaine are 15-17 mg (3.0-3.4 mL) and 10.5-16 mg (2.1-3.2 mL) for patients aged <60 and ≥60 years, respectively.

Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis.

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

A randomized comparison of hemodynamic changes in response to a heart rate-dependent phenylephrine/ephedrine protocol versus ephedrine-only for spinal hypotension during elective cesarean section.

AIM: To compare incidences of abnormal heart rate (HR) between the phenylephrine/ephedrine protocol (P/E protocol) against the ephedrine-only (C) protocol, conventionally used for treating predelivery hypotension following spinal anesthesia for cesarean section. METHODS: Two hundred and sixty-eight parturients with pre-delivery hypotension after spinal anesthesia were equally randomized to (1) Group P/E (n = 134), phenylephrine 100 mcg in 10 mL intravenously if HR ≥ 60 beats/min (bpm), or ephedrine 6 mg intravenously if HR < 60 bpm, and 2) Group C (n = 134). The primary outcome was the incidence of the parturients with abnormal HR after vasopressor administration. The secondary outcome was the mean differences of HR and hypotensive periods during the pre-delivery period. RESULTS: There was no significant difference of between-group incidences of bradycardia (12.0% in Group P/E vs 6.7% in Group C, p = 0.136) and tachycardia (26.9% vs 35.8%, p = 0.114). Mean HR was 81.9 bpm (95% confidence interval [CI] 79.9, 84.3) in Group P/E, and 88.8 bpm (86.8, 90.6) in Group C (p < 0.001). The duration of hypotension in relation to the time interval from spinal anesthesia to delivery was 20.9% (95% CI 18.4-23.2) in Group P/E, and 26.5% (23.9-29.3) in Group C (p < 0.01). The calculated area under the curve (AUC) of abnormal HR in relation to time was significantly reduced only in Group P/E (p < 0.010). CONCLUSIONS: The incidences of out-of-range HR were comparable, but the P/E protocol resulted in a lower mean HR and better control of systolic blood pressure than the ephedrine-only protocol.

The potential role of dexmedetomidine on neuroprotection and its possible mechanisms: Evidence from in vitro and in vivo studies.

Neurological disorders following brain injuries and neurodegeneration are on the rise worldwide and cause disability and suffering in patients. It is crucial to explore novel neuroprotectants. Dexmedetomidine, a selective α2-adrenoceptor agonist, is commonly used for anxiolysis, sedation and analgesia in clinical anaesthesia and critical care. Recent studies have shown that dexmedetomidine exerts protective effects on multiple organs. This review summarized and discussed the current neuroprotective effects of dexmedetomidine, as well as the underlying mechanisms. In preclinical studies, dexmedetomidine reduced neuronal injury and improved functional outcomes in several models, including hypoxia-induced neuronal injury, ischaemic-reperfusion injury, intracerebral haemorrhage, post-traumatic brain injury, anaesthetic-induced neuronal injury, substance-induced neuronal injury, neuroinflammation, epilepsy and neurodegeneration. Several mechanisms are associated with the neuroprotective function of dexmedetomidine, including neurotransmitter regulation, inflammatory response, oxidative stress, apoptotic pathway, autophagy, mitochondrial function and other cell signalling pathways. In summary, dexmedetomidine has the potential to be a novel neuroprotective agent for a wide range of neurological disorders.

Predicting Survival in Thai Patients After Low Impact Hip Fracture Using Flexible Parametric Modelling: A Retrospective Cohort Study.

Predictive post-hip fracture mortality models have been presented for specific time points (in-hospital, 30-days or 1-year) and most provide marginal predictions based on the patient's risk group. However, the predictive model for individual survival probability following hip fracture is not available. This study aimed to develop a flexible parametric model for predicting individual survival probability for hip fracture patients. In this retrospective study, the medical charts of 765 Thai patients admitted to hospital with a hip fracture resulting from low-impact injury from January 2014 to December 2018 were reviewed. Predictors for all-cause mortality were identified using flexible parametric survival analysis and were used to develop the predictive model. The model was calibrated using a calibration graph and discrimination performance was evaluated using the C-statistic. Internal validity was assessed using bootstrapping. The overall mortality rate of the hip fracture patients was 14%. Predictors significantly associated with survival after hip fracture were age, active malignancy, dementia or Alzheimer's disease, chronic obstructive pulmonary disorder, diabetes mellitus, hemoglobin concentration, eGFR<30 mL/min/1.73m2 and operative treatments. The model-predicted survival was similar to that actually observed in the very low survival group in the first year after hip fracture. In bootstrapping, the apparent C-statistic and the test C-statistic of the reduced model were 0.79 (95% CI 0.77-0.81) and 0.79 (95% CI 0.78-0.80), respectively. The flexible survival model provides good predictive power for individual survival probability at any given time point within the first year after hip fracture and would be an easy to use tool in clinical practice.

Transferability of the early-stage ovarian malignancy (EOM) score: an external validation study that includes advanced-stage and metastatic ovarian cancer.

PURPOSE: To validate the diagnostic performance of the Early-stage Ovarian Malignancy (EOM) score in an external dataset that includes advanced-stage and metastatic ovarian cancer. METHODS: The data from two cross-sectional cohorts were used in the statistical analysis. The development dataset of the EOM score was collected in Phrapokklao Hospital between September 2013 and December 2017. The validation dataset was collected in Maharaj Nakorn Chiang Mai Hospital between April 2010 and March 2018. The internal and external performance of the EOM score was evaluated in terms of discrimination via area under the receiver-operating characteristic curve (AuROC) and calibration. RESULTS: There were 270 and 479 patients included in the development and validation datasets, respectively. The prevalence of ovarian malignancy was 20.0% (54/270) in the development set and 30.3% (145/479) in the validation set. The EOM score had excellent discriminative ability in both the development and validation sets (AuROC 88.0 (95% CI 82.6, 93.9) and 88.0 (95% CI 84.3, 91.4), respectively). The EOM score also showed good calibration in both datasets. CONCLUSIONS: The EOM score had consistent diagnostic performance in the external validation data. It is recommended for use as a triage tool in patient referrals instead of the RMI in settings where experienced sonographers are not available.

The role of perceived stress and cognitive function on the relationship between neuroticism and depression among the elderly: a structural equation model approach.

BACKGROUND: Depression comprises common psychological problems, and has been strongly related to neuroticism and perceived stress. While neuroticism has been shown to have a direct effect on depression, it also has an indirect effect via perceived stress. Among the elderly, cognitive function produces influences that should not be overlooked when investigating depression. This study aimed to determine the role of mediating effects of perceived stress as well as cognitive function on neuroticism and depression among elderly patients. METHODS: This research constituted a secondary analysis, with data collected during the pre-operative period of 429 elderly individuals undergoing elective, noncardiac surgery. The evaluation included the Perceived Stress Scale, the Neuroticism Inventory, the Montreal Cognitive Assessment, and the Geriatric Depression Scale. Structural equation modeling was used to investigate the hypothesized model. RESULTS: Neuroticism exhibited a significant indirect effect on perceived stress via depression and cognition (ß = 0.162, 95% CI 0.026, 0.322, p = .002). Neuroticism initially had a direct effect on depression (ß = 0.766, 95% CI 0.675, 0.843 p = 0.003); thereafter, it was reduced after covariates were added (ß = 0.557, 95% CI 0.432, 0.668 p = 0.002). Based on this model, the total variance explained by this model was 67%, and the model showed an acceptable fit with the data. CONCLUSIONS: Both perceived stress and cognitive function partially mediated the effect of neuroticism on depression, with perceived stress exhibiting a greater effect. TRIAL REGISTRATION: The study protocol has been registered at Clinicaltrials.gov under registered number: NCT02131181.

Acute kidney injury risk prediction score for critically-ill surgical patients.

BACKGROUND: There has been a global increase in the incidence of acute kidney injury (AKI), including among critically-ill surgical patients. AKI prediction score provides an opportunity for early detection of patients who are at risk of AKI; however, most of the AKI prediction scores were derived from cardiothoracic surgery. Therefore, we aimed to develop an AKI prediction score for major non-cardiothoracic surgery patients who were admitted to the intensive care unit (ICU). METHODS: The data of critically-ill patients from non-cardiothoracic operations in the Thai Surgical Intensive Care Unit (THAI-SICU) study were used to develop an AKI prediction score. Independent prognostic factors from regression analysis were included as predictors in the model. The outcome of interest was AKI within 7 days after the ICU admission. The AKI diagnosis was made according to the Kidney Disease Improving Global Outcomes (KDIGO)-2012 serum creatinine criteria. Diagnostic function of the model was determined by area under the Receiver Operating Curve (AuROC). Risk scores were categorized into four risk probability levels: low (0-2.5), moderate (3.0-8.5), high (9.0-11.5), and very high (12.0-16.5) risk. Risk of AKI was presented as likelihood ratios of positive (LH+). RESULTS: A total of 3474 critically-ill surgical patients were included in the model; 333 (9.6%) developed AKI. Using multivariable logistic regression analysis, older age, high Sequential Organ Failure Assessment (SOFA) non-renal score, emergency surgery, large volume of perioperative blood loss, less urine output, and sepsis were identified as independent predictors for AKI. Then AKI prediction score was created from these predictors. The summation of the score was 16.5 and had a discriminative ability for predicting AKI at AuROC = 0.839 (95% CI 0.825-0.852). LH+ for AKI were: low risk = 0.117 (0.063-0.200); moderate risk = 0.927 (0.745-1.148); high risk = 5.190 (3.881-6.910); and very high risk = 9.892 (6.230-15.695), respectively. CONCLUSIONS: The function of AKI prediction score to predict AKI among critically ill patients who underwent non-cardiothoracic surgery was good. It can aid in early recognition of critically-ill surgical patients who are at risk from ICU admission. The scores could guide decision making for aggressive strategies to prevent AKI during the perioperative period or at ICU admission. TRIAL REGISTRATION: TCTR20190408004, registered on April 4, 2019.

A Comparison of the external anatomical landmark and the radiological landmark for obtaining the optimal depth of a right internal jugular venous catheter in pediatric cardiac patients.

BACKGROUND: The external anatomical landmark and the radiological landmark have been introduced to provide estimation of the depth of right internal jugular venous catheter during insertion. AIMS: This study aimed to compare the accuracy, agreement, and reliability of the external anatomical landmark and the radiological landmark, confirmation being by transesophageal echocardiography. METHODS: This prospective observational study was conducted in children ages 1-15 years. The catheter was placed at the superior vena cava and the right atrium junction guided by transesophageal echocardiography. The catheter depth derived from the transesophageal echocardiography, the external anatomical landmark, and the radiological landmark was recorded. The optimal zone of the catheter tip was 5 mm below and 10 mm above the superior vena cava and the right atrium junction. Accuracy was assessed by the difference between the transesophageal echocardiography and the external anatomical landmark or the radiological landmark. Agreement with Bland-Altman plots and correlation were tested. RESULTS: Eighty participants, median age of 3 years, were enrolled. The median (IQR) differences between the depth of the transesophageal echocardiography and the external anatomical landmark or the radiological landmark were 0.30 (0, 0.70) and 0.10 (-0.20, 0.90) cm, respectively. Bland-Altman plots demonstrated good agreement between the depths. The catheter tips were located in the optimal zone more frequently with the external anatomical landmark than the radiological landmark (94.7% vs 64.5%). The external anatomical landmark showed a stronger correlation to transesophageal echocardiography than the radiological landmark (r = .95 vs .83). CONCLUSION: Both the external anatomical landmark and the radiological landmark enabled accurate estimation of the central venous catheter depth close to the superior vena cava and the right atrium junction. The external anatomical landmark is of more potential use than the radiological landmark in clinical practice.

Role of perceived stress in postoperative delirium: an investigation among elderly patients.

Objectives: This study examined levels of perceived stress (PS), postoperative delirium (POD) and associated factors among Thai elderly patients undergoing elective noncardiac surgery.Background and aims: Preoperative PS and change after operation have not been widely studied. Moreover, psychological factors associated with PS and POD has been poorly investigated.Materials and Methods: In total, 429 elderly patients were recruited at a university hospital. The preoperative evaluation included sociodemographic data, health behaviors at risk, Perceived Stress Scale (PSS-10), Neuroticism Inventory (NI), Mental State Examination T10 (MSET10), Montreal Cognitive Assessment (MoCA) and Geriatric Depression Scale (GDS-15). Three-day postoperative evaluation included PSS-10 and Confusion Assessment Method Algorithm (CAM) or CAM-ICU for Delirium. Multiple regression and logistic regression analysis were performed to determine potential predictors.Results: Females were 58.97%, and the mean age was 69.93 ± 6.87 years. Mean pre- and postoperative PS were 12.77 ± 5.41 and 13.39 ± 5.26, respectively (P < 0.05). Multiple regression revealed that neuroticism, depression, and BMI predicted PS significantly. None of the independent variables was found to predict postoperative PS except for preoperative PS (p <.001). POD at the recovery room was predicted by preoperative PS (odds ratio = 1.181, 95% CI = 1.019-1.369), whereas overall POD was predicted by MoCA (odds ratio = .864, 95% CI = .771 -.968).Conclusion: Preoperative PS was significant in that it was associated with postoperative PS and POD. A careful assessment of preoperative PS as well as providing brief interventions for patients with high levels of this condition may reduce the risk of POD.

Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study.

Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.

Prognostic Factors for All-Cause Mortality in Thai Patients with Fragility Fracture of Hip: Comorbidities and Laboratory Evaluations.

Background and Objectives: Although the types of comorbidities and laboratory evaluations are major factors associated with mortality after hip fractures, there have been no studies of the association of these factors and mortality in Thai hip-fracture patients. This study aimed to identify prognostic factors associated with mortality after a hip fracture in the Thai population, including types of comorbidities, treatment-related factors, and laboratory evaluations. Materials and Methods: This five-year retrospective study was conducted in a tertiary care hospital in Thailand. A total of 775 Thai patients who had been admitted with a hip fracture resulting from a simple fall were identified using the International Classification of Disease 10 codes, and a review of their medical charts was conducted. Associations between general factors, comorbidities, laboratory evaluations, treatment factors including type of treatment, and time to death were analyzed using the Cox proportional hazard regression and the hazard ratio (HR). Results: The overall mortality rate of hip fracture patients was 13.94%. Independent prognostic factors found to be significantly associated with mortality were nonoperative treatment (HR = 3.29, p < 0.001), admission glomerular filtration rate (GFR) < 30 mL/min/1.73 m2 (HR = 3.40, p < 0.001), admission hemoglobin concentration <10 g/dL. (HR = 2.31, p < 0.001), chronic obstructive pulmonary disorder (HR = 2.63, p < 0.001), dementia or Alzheimer's disease (HR = 4.06, p < 0.001), and active malignancy (HR = 6.80, p < 0.001). Conclusion: The types of comorbidities and laboratory evaluation findings associated with mortality in Thai patients with hip fractures include chronic obstructive pulmonary disorder, dementia or Alzheimer's disease, active malignancy, admission GFR < 30 mL/min/1.73 m2, and admission hemoglobin concentration <10 g/dL. The risks of mortality for Thai hip-fracture patients with these comorbidities or laboratory evaluation findings were 2.5, 4, 7, 3.5, and 2.5 times higher, respectively, than patients without those factors.

Early-Stage Ovarian Malignancy Score versus Risk of Malignancy Indices: Accuracy and Clinical Utility for Preoperative Diagnosis of Women with Adnexal Masses.

Background and objectives: To compare the diagnostic accuracy and clinical utility of the Early-stage Ovarian Malignancy (EOM) score with the Risk of Malignancy Index (RMI) in the presurgical assessment of women presenting with adnexal masses. Materials and Methods: A secondary analysis was carried out in a retrospective cohort of women who presented with an adnexal mass and were scheduled for surgery at Phrapokklao Hospital between September 2013 and December 2017. The clinical characteristics, ultrasonographic features of the masses, and preoperative CA-125 levels were recorded. The EOM and the RMI score were calculated and compared in terms of accuracy and clinical utility. Decision curve analysis (DCA), which examined the net benefit (NB) of applying the EOM and the RMI in practice at a range of threshold probabilities, was presented. Results: In this study, data from 270 patients were analyzed. Fifty-four (20.0%) women in the sample had early-stage ovarian cancer. All four RMI versions demonstrated a lower sensitivity for the detection of patients with early-stage ovarian cancer compared to an EOM score ≥ 15. An EOM ≥ 15 resulted in a higher proportion of net true positive or NB than all versions of the RMIs from a threshold probability of 5% to 30%. Conclusions: It also showed a higher capability to reduce the number of inappropriate referrals than the RMIs at a threshold probability between 5% and 30%. The EOM score showed higher diagnostic sensitivity and has the potential to be clinically more useful than the RMIs to triage women who present with adnexal masses for referral to oncologic gynecologists. Further external validation is required to support our findings.

The Effectiveness of Intravenous Parecoxib on the Incidence of Ipsilateral Shoulder Pain After Thoracotomy: A Randomized, Double-Blind, Placebo-Controlled Trial.

OBJECTIVES: To determine the incidence of ipsilateral shoulder pain (ISP) with the therapeutic use of parecoxib compared with a placebo after thoracotomy. DESIGN: A prospective, randomized, double-blind, placebo-controlled trial. SETTING: A tertiary-care university hospital. PARTICIPANTS: Adult patients undergoing an elective thoracotomy between June 2011 and February 2015. INTERVENTIONS: Patients were allocated randomly into the parecoxib group (n = 80) and the control group (n = 80). In the parecoxib group, 40 mg of parecoxib was diluted into 2 mL and given intravenously 30 minutes before surgery and then every 12 hours postoperatively for 48 hours. In the control group, 2 mL of normal saline was given to the patients at the same intervals. MEASUREMENTS AND MAIN RESULTS: A numerical rating scale was used to assess the intensity of ISP at 2, 6, 12, 24, 48, 72, and 96 hours after surgery. Intravenous morphine (0.05 mg/kg) was used as the rescue medication for ISP during the 96-hour period. Baseline characteristics of patients in both groups were comparable. Patients in the parecoxib group had a significantly lower incidence of ISP, both overall (42.5% v 62.0%, p = 0.014) and of moderate-to-severe ISP when compared with the control group (26.2% v 49.4%, p = 0.003). Parecoxib reduced the risk of ISP by a statistically significant 32% (risk ratio, 0.68; 95% confidence interval, 0.50-0.93, p = 0.016). There were no significant differences in the occurrence of adverse effects between the groups. CONCLUSIONS: Intravenous parecoxib significantly can reduce the incidence and severity of ISP after thoracotomy.

A Multi-center Thai University-based Surgical Intensive Care Unit Study (THAI-SICU Study): Incidence of Acute Myocardial Infarction and Associated Factors.

Introduction: To describe the incidence, characteristics and outcomes of acute myocardial infarction (AMI) and determine risk factor(s) of AMI in THAI-surgical intensive care unit (SICU). Material and Method: This study was multicenter prospective cohorts study that conducted data from 9 university-affiliated SICUs in Thailand between April 2011 and January 2013. We collected and evaluated data of AMI events. The patients were followed-up for up to 28 days after admitted to the SICUs. Results: The overall incidence of AMI in SICU was 1.4% (66 of 4,652 patients). Non-ST elevated MI was the most common electrocardiography (ECG) presentation (75%). The common clinical sign and symptom of AMI included ECG changes (53%) and elevation of cardiac enzymes (48.5%). Patients with AMI had significantly higher 28-day mortality rate (28.8% versus 13.6%, p<0.001) than those with non-MI. The Acute Physiologic and Chronic Health Evaluation (APACHE) II scores (RR 1.04, 95% CI 1.01-1.07, p = 0.003) and age >65 year (RR 2.54, 95% CI 1.36-4.75, p = 0.003) were significant risk factors of AMI. Conclusion: The incidence of AMI in the SICU was uncommon but led to significantly higher mortality rates. The APACHE II score and age ≥65 year were significant predictors of AMI in SICU.

Incidence of Cardiac Arrest and Related Factors in a Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study)

Objective: To describe the incidences, outcomes and determine the risk factor(s) of cardiac arrest in surgical intensive care unit (SICU). Material and Method: We collected data between April 2011 and January 2013. The case record form (CRF) included the CRF 1 (admission, daily screening and discharge data) and the CRF 2 for cardiac arrest events. The patients were followed-up until discharge from SICU or for up to 28 days after admission in SICU. Results: The incidence of cardiac arrest in SICU was 226 in 4,652 patients (4.9%). The APACHE II score at the day with cardiac arrest were 24.1. Initial monitor rhythm during cardiac was asystole (35.4%), bradycardia (22.6%) and pulseless electrical activity (14.6%). The main cause was poor patient condition before admission (51.3%). Most of the cardiac arrest patients (73.9%) had antecedents within 24 hour and the most common antecedents were hypotension, metabolic disturbances and sepsis and/or septic shock. The overall return of spontaneous circulation rate was 23.5%. At hospital discharge, the mortality rate (91.6%) was statistically different between the cardiac arrest and non-cardiac arrest group (p<0.001). The Acute Physiologic and Chronic Health Evaluation II score (APACHE II score) (Odds ratio, (OR 1.15, 95% CI 1.11-1.19, p<0.001), Sequential Organ Failure Assessment score (SOFA score) (OR 1.12, 95% CI 1.03-1.20, p = 0.005) and American Society of Anesthesiologists physical status physical status (ASA PS) ≥3 (OR 2.32, 95% CI 1.33-4.04, p = 0.003) were significantly risk factors for cardiac arrest. Conclusion: Cardiac arrest in the SICU was uncommon. Initial non-shockable rhythms were common and mostly had antecedents before cardiac arrest. The APACHE II score, SOFA score and ASA PS ≥3 were independent risk factors for cardiac arrest in SICU.

The Impact of Delirium on Clinical Outcomes in Multi-Center Thai Surgical Intensive Care Units: A Prospective Cohort Study.

Objective: Delirium in intensive care units (ICU) increases risks in prolonged mechanical ventilation, hospitalization, and mortality rate. The purpose of this study is to determine if delirium in the surgical intensive care units (SICU) is an independent predictor of clinical outcomes during hospitalization. Material and Method: A multi-center, prospective cohort study was conducted between April 2011 and January 2013. All patients who were admitted to nine university-based SICU were enrolled. Delirium was diagnosed by using the Intensive Care Delirium Screening Checklists. The clinical outcomes of study included length of mechanical ventilation, length of hospital stay, ICU and 28 day mortality. Cox proportional hazard regression model was used to assess the effects of delirium on ICU and 28 day mortality. Results: A total of 4,652 patients were included. One hundred and sixty-three patients were diagnosed delirium (3.5%, 163 of 4,652). Patients who experienced delirium during ICU admission were significantly older (65.0+15.8 years versus 61.6+17.3 years, p = 0.013), had higher American Society of Anesthesiologists physical status (24.3% versus 12.2%, p<0.001), higher Acute Physiology and Chronic Health Evaluation II score (16 (12-23) versus 10 (7-15), p<0.001), and higher Sequential Organ Failure Assessment score (5 (2-8) versus 2 (1-5), p<0.001) compared to non-delirium. Delirious patients also had higher ventilator days (7 (4-17) versus 2 (1-4), p<0.001, longer length of hospital stay (22 (14-34) versus 15 (9-26), p<0.001) and higher ICU mortality (24% versus 9%, p<0.001), and 28-day mortality (28% versus 13%, p<0.001). Patients who developed delirium in the intensive care unit were associated with increased 28-day mortality (adjusted HR = 2.47, 95% CI: 1.13-5.41, p = 0.023). Conclusion: Delirium in an ICU was a major predictor of hospital mortality after adjusted for relevant covariates. Routine monitoring of delirium, early detection, and implementation of preventive strategy are recommended.

Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery.

OBJECTIVES: This study was designed to determine the incidence and risk factors associated with ipsilateral shoulder pain (ISP) after thoracic surgery and to investigate characteristics, locations, and severity of ISP. DESIGN: A prospective observational study. SETTING: University hospital. PARTICIPANTS: Two hundred five patients who underwent thoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pain at the incisional site and shoulder pain were assessed separately using the numeric rating scale (NRS) during the patients' stay in the postanesthesia care unit. The overall incidence of ISP was 47.3%. The incidence of ISP in thoracotomy patients (58.7%) was substantially higher than in video-assisted thoracoscopic surgery patients (20.9%). ISP was described most often as a dull aching pain (87%). In approximately half of the patients, ISP was located at the posterior side of the shoulder. The severity of ISP was classified as moderate to severe in 67% of patients. The potential risk factors associated with ISP were surgery using the thoracotomy approach (risk ratio: 2.12, 95% confidence interval: 1.16-3.86, p=0.014) and surgical duration>120 minutes (risk ratio: 1.61, 95% confidence interval: 1.07-2.44, p=0.023). CONCLUSIONS: The incidence of ISP after thoracic surgery was high and the severity of pain was significant. The thoracotomy approach and the long duration of surgery are potential risk factors for ISP.