Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial.

OBJECTIVE: To assess whether delaying appendectomy until the following morning is non-inferior to immediate surgery in those with acute appendicitis presenting at night. BACKGROUND: Despite a lack of supporting evidence, those with acute appendicitis who present at night frequently have surgery delayed until the after morning. METHODS: The delay trial is a noninferiority randomized controlled trial conducted between 2018 and 22 at 2 tertiary care hospitals in Canada. Adults with imaging confirmed acute appendicitis who presented at night (8:00 pm -4:00 am ). Delaying surgery until after 6:00 am was compared with immediate surgery. The primary outcome was 30-day postoperative complications. An a prior noninferiority margin of 15% was deemed clinically relevant. RESULTS: One hundred twenty-seven of the planned 140 patients were enrolled in the Delayed Versus Early Laparoscopic Appendectomy (DELAY) trial (59 in the delayed group and 68 in the immediate group). The two groups were similar at baseline. The mean time between the decision to operate and surgery was longer in the delayed group (11.0 vs 4.4 hours, P < 0.0001). The primary outcome occurred in 6/59 (10.2%) of those in the delayed group versus 15/67 (22.4%) of those in the immediate group ( P = 0.07). The difference between groups met the a priori noninferiority criteria of +15% (risk difference -12.2%, 95% CI: -24.4% to +0.4%, test of noninferiority P < 0.0001). CONCLUSIONS: The DELAY study is the first trial to assess delaying appendectomy in those with acute appendicitis. We demonstrate the noninferiority of delaying surgery until the after morning.

Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

The influence of surgical and procedural rotations and interest in a surgical discipline on medical students' suturing ability during clerkship.

BACKGROUND: Although suturing is an essential competency for medical students, there has been limited research into the skills acquisition process over the course of medical school curriculum. This study aimed to determine whether suturing ability improved over the course of clerkship and whether an interest in a surgical discipline was associated with improved skill acquisition. METHODS: The suturing ability of third-year medical students at a large Canadian medical school was assessed at the beginning of clerkship (August 2018) as well as before and after their surgery rotation by 2 expert reviewers using a validated, objective scoring system as well as a qualitative assessment, both in person and via blinded video recordings. Students were randomly allocated to 4 groups for their clerkship year by the medical school. RESULTS: Of 133 eligible students, 115 (86.5%) completed the study. Median suturing assessment scores improved significantly after the surgery rotation (214.5 [interquartile range (IQR) 191.1-235.0] v. 238.0 [IQR 223.5-255.0], p = 0.001). Groups that had completed a procedural rotation (emergency medicine, obstetrics and gynecology) between clerkship and starting their surgery rotation had improved scores between these time points (p < 0.05), whereas scores decreased for groups that did not have a procedural rotation between assessments. Regardless of previous rotations, suturing scores were similar between groups after the surgery rotation. The 21 students (18.3%) who were interested in a surgical discipline had higher suturing scores than students who were not interested in surgery at the beginning of clerkship (229.1 [IQR 220.2-253.0] v. 208.0 [IQR 185.0-228.0], p < 0.001) and after the surgery rotation (252.0 [IQR 227.0-268.0] v. 235.8 [IQR 220.5-251.2], p = 0.02). CONCLUSION: Medical students' suturing ability improved during the surgery rotation but was also influenced by other procedural rotations and students' interest in procedure specialties. Skill acquisition by medical students is complex and requires additional investigation.

An interpretable multi-task system for clinically applicable COVID-19 diagnosis using CXR.

BACKGROUND: With the emergence of continuously mutating variants of coronavirus, it is urgent to develop a deep learning model for automatic COVID-19 diagnosis at early stages from chest X-ray images. Since laboratory testing is time-consuming and requires trained laboratory personal, diagnosis using chest X-ray (CXR) is a befitting option. OBJECTIVE: In this study, we proposed an interpretable multi-task system for automatic lung detection and COVID-19 screening in chest X-rays to find an alternate method of testing which are reliable, fast and easily accessible, and able to generate interpretable predictions that are strongly correlated with radiological findings. METHODS: The proposed system consists of image preprocessing and an unsupervised machine learning (UML) algorithm for lung region detection, as well as a truncated CNN model based on deep transfer learning (DTL) to classify chest X-rays into three classes of COVID-19, pneumonia, and normal. The Grad-CAM technique was applied to create class-specific heatmap images in order to establish trust in the medical AI system. RESULTS: Experiments were performed with 15,884 frontal CXR images to show that the proposed system achieves an accuracy of 91.94% in a test dataset with 2,680 images including a sensitivity of 94.48% on COVID-19 cases, a specificity of 88.46% on normal cases, and a precision of 88.01% on pneumonia cases. Our system also produced state-of-the-art outcomes with a sensitivity of 97.40% on public test data and 88.23% on a previously unseen clinical data (1,000 cases) for binary classification of COVID-19-positive and COVID-19-negative films. CONCLUSION: Our automatic computerized evaluation for grading lung infections exhibited sensitivity comparable to that of radiologist interpretation in clinical applicability. Therefore, the proposed solution can be used as one element of patient evaluation along with gold-standard clinical and laboratory testing.

Focal Laser Ablation of Prostate Cancer: Results in 120 Patients with Low- to Intermediate-Risk Disease.

PURPOSE: Can focal laser ablation (FLA) of low to intermediate risk prostate cancer preserve sexual and urinary function with low morbidity while providing adequate oncologic outcomes. MATERIALS AND METHODS: Transrectal FLA was done in 120 patients with low- to intermediate-risk prostate cancer. MR imaging thermometry controlled ablation. At 6 and 12 months, patients had clinical and MR imaging follow-up with biopsy of suspicious areas. Patients submitted surveys of sexual and urinary function. Multivariate logistic regression identified determinants of positive imaging and biopsies. Two-sided Wilcoxon signed rank test evaluated scores and laboratory values. RESULTS: Median patient age was 64 years, and median prostate-specific antigen (PSA) was 6.05 ng/mL. Median follow-up period was 34 months (range, 17-55 months). Gleason score was 3+3=6 in 37 (30.8%), 3+4=7 in 56 (46.7%), and 4+3=7 in 27 (22.5%) patients. Tumor stage was T1c in 89 (74.2%), T2a in 26 (21.7%), and T2b in 5 (4.2%) patients. Twenty (17%) patients had additional oncologic therapy 1 year after FLA when biopsy confirmed cancer following abnormal MR imaging. There was no difference between functional scores before and after ablation. Median PSA decreased to 3.25 at 12 months (P < .001). Tumor diameter above the median (odds ratio = 3.36; 95% confidence interval, 1.41-7.97) was the only significant predictor for positive MR imaging after treatment. CONCLUSIONS: One year after FLA, selected patients had low morbidity, no significant changes in quality of life, and 83% freedom of retreatment rate. Sexual and urinary function did not significantly change after FLA.

Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline.

The American College of Emergency Physicians (ACEP) organized a multidisciplinary effort to create a clinical practice guideline specific to unscheduled, time-sensitive procedural sedation, which differs in important ways from scheduled, elective procedural sedation. The purpose of this guideline is to serve as a resource for practitioners who perform unscheduled procedural sedation regardless of location or patient age. This document outlines the underlying background and rationale, and issues relating to staffing, practice, and quality improvement.

Initial series of magnetic resonance imaging (MRI)-fusion targeted prostate biopsy using the first transperineal targeted platform available in the USA.

OBJECTIVES: To describe a step-by-step guide for using the first transperineal targeted prostate biopsy platform available in the USA. PATIENTS AND METHODS: A total of 32 men with elevated prostate-specific antigen (PSA) levels were diagnosed with a region of interest on multiparametric magnetic resonance imaging (mpMRI) between February 2017 and January 2018. The transperineal targeted prostate biopsy procedure was accomplished via a transperineal approach and used a stepper, combined with advanced mpMRI/transrectal ultrasound fusion software, to perform targeted prostate biopsy. The detection of overall and clinically significant prostate cancer (PCa) was assessed as well as the rate of complications. RESULTS: The median patient age was 68.0 years and the median PSA was 8.0 ng/mL. Two patients (6%) were active surveillance candidates and 16 (50%) had a prior negative prostate biopsy. The detection rates for overall and clinically significant PCa were 81% and 59%, respectively. The two candidates for active surveillance and eight of the patients with a prior negative prostate biopsy had clinically significant PCa confirmed on targeted biopsy. There were no peri-operative complications. CONCLUSION: These results demonstrate the promising potential of the first transperineal targeted prostate biopsy platform in the USA as an alternative diagnostic method for PCa.

Checklists for Image-Guided Interventions.

OBJECTIVE: Checklists are tools commonly used to help confirm that certain tasks of a process are completed. Within the health care industry, medical checklists are recognized as a means to improve patient safety. CONCLUSION: Recent application of checklists to image-guided interventions has shown positive outcomes; however, there are limited published studies. We review the literature regarding checklist use as a safety measure and focus on implementation of checklists for image-guided interventions.

MRI-Guided Prostate Interventions.

OBJECTIVE: The objective of this study is to discuss the use of MRI-guided and MRI-directed prostate biopsy techniques, describe how interventional MRI focal therapies are used for the treatment of prostate cancer, and predict future directions in prostate interventional MRI. The prospect of establishing a center for prostate imaging, diagnosis, and treatment is also discussed. CONCLUSION: Low- or intermediate-risk prostate cancer can be safely treated with MRI-compatible devices and techniques such as biopsy, cryoablation, high-intensity focused ultrasound, or focal laser ablation performed from a transrectal or transperineal approach. Although the long-term effectiveness of focal therapy for prostate cancer is unknown, the effect on urinary or sexual function is extremely low. These procedures are attracting an increasing number of men who view focal therapies as a better alternative to the uncertainty of no therapy and the more radical whole-gland surgical and radiation therapies with their higher complication rates.

Insurance Type and Withdrawal of Life-Sustaining Therapy in Critically Injured Trauma Patients.

Importance: Withdrawal of life-sustaining therapy (WLST) decisions for critically injured trauma patients are complicated and multifactorial, with potential for patients' insurance status to affect decision-making. Objectives: To determine if patient insurance type (private insurance, Medicaid, and uninsured) is associated with time to WLST in critically injured adults cared for at US trauma centers. Design, Setting, and Participants: This retrospective registry-based cohort study included reported data from level I and level II trauma centers in the US that participated in the American College of Surgeons Trauma Quality Improvement Program (TQIP) registry. Participants included adult trauma patients who were injured between January 1, 2017, and December 31, 2020, and required an intensive care unit stay. Patients were excluded if they died on arrival or in the emergency department or had a preexisting do not resuscitate directive. Analyses were performed on December 12, 2023. Exposures: Insurance type (private insurance, Medicaid, uninsured). Main Outcomes and Measures: An adjusted time-to-event analysis for association between insurance status and time to WLST was performed, with analyses accounting for clustering by hospital. Results: This study included 307 731 patients, of whom 160 809 (52.3%) had private insurance, 88 233 (28.6%) had Medicaid, and 58 689 (19.1%) were uninsured. The mean (SD) age was 40.2 (14.1) years, 232 994 (75.7%) were male, 59 551 (19.4%) were African American or Black patients, and 201 012 (65.3%) were White patients. In total, 12 962 patients (4.2%) underwent WLST during their admission. Patients who are uninsured were significantly more likely to undergo earlier WLST compared with those with private insurance (HR, 1.54; 95% CI, 1.46-1.62) and Medicaid (HR, 1.47; 95% CI, 1.39-1.55). This finding was robust to sensitivity analysis excluding patients who died within 48 hours of presentation and after accounting for nonwithdrawal death as a competing risk. Conclusions and Relevance: In this cohort study of US adult trauma patients who were critically injured, patients who were uninsured underwent earlier WLST compared with those with private or Medicaid insurance. Based on our findings, patient's ability to pay was may be associated with a shift in decision-making for WLST, suggesting the influence of socioeconomics on patient outcomes.

Resuscitative transesophageal echocardiography during the acute resuscitation of trauma: A retrospective observational study.

BACKGROUND: Resuscitative transesophageal echocardiography (TEE) is an emerging POCUS modality that can be used to guide trauma resuscitation. METHODS: Trauma patients who underwent TEE within 24 h of admission from 2013 to 2022 were prospectively identified. We retrospectively analyzed resuscitative TEE reports and patient charts in duplicate. RESULTS: 29 providers performed TEE for 54 acute trauma patients. 28 (52%) died in hospital; 33 (61%) required operative intervention (<24 h). Median injury severity score was 29 [IQR 22-43]. The most common indications for TEE were hemodynamic instability (34, 63%), inadequate windows for transthoracic echocardiography (14, 26%) and cardiac arrest (11, 20%). There were no identified complications. A new diagnosis was made in 31 (57%) cases: most commonly right ventricular dysfunction (10, 19%), pericardial effusion (9, 17%), and hypovolemia (6, 11%). TEE ruled out major cardiac injury in 83% of cases. TEE changed resuscitative strategy, in 17 (32%) patients, diagnostic imaging approach in 6 (11%) patients, procedural or operative approach in 5 (9%) patients and disposition from the trauma bay in 4 (7%) patients. CONCLUSION: Resuscitative TEE during acute trauma care has an additional diagnostic yield to existing diagnostic pathways and may impact definitive management for some patients in the trauma bay.

Multi-modal learning for inpatient length of stay prediction.

Predicting inpatient length of stay (LoS) is important for hospitals aiming to improve service efficiency and enhance management capabilities. Patient medical records are strongly associated with LoS. However, due to diverse modalities, heterogeneity, and complexity of data, it becomes challenging to effectively leverage these heterogeneous data to put forth a predictive model that can accurately predict LoS. To address the challenge, this study aims to establish a novel data-fusion model, termed as DF-Mdl, to integrate heterogeneous clinical data for predicting the LoS of inpatients between hospital discharge and admission. Multi-modal data such as demographic data, clinical notes, laboratory test results, and medical images are utilized in our proposed methodology with individual "basic" sub-models separately applied to each different data modality. Specifically, a convolutional neural network (CNN) model, which we termed CRXMDL, is designed for chest X-ray (CXR) image data, two long short-term memory networks are used to extract features from long text data, and a novel attention-embedded 1D convolutional neural network is developed to extract useful information from numerical data. Finally, these basic models are integrated to form a new data-fusion model (DF-Mdl) for inpatient LoS prediction. The proposed method attains the best R2 and EVAR values of 0.6039 and 0.6042 among competitors for the LoS prediction on the Medical Information Mart for Intensive Care (MIMIC)-IV test dataset. Empirical evidence suggests better performance compared with other state-of-the-art (SOTA) methods, which demonstrates the effectiveness and feasibility of the proposed approach.

Antiplatelets versus anticoagulants in the treatment of blunt cerebrovascular injury (BCVI) - A systematic review and meta-analysis.

INTRODUCTION: Blunt cerebrovascular injury (BCVI) occurs in 1-3% of blunt traumas and is associated with stroke, disability, and mortality if unrecognized and untreated. Early detection and treatment are imperative to reduce the risk of stroke, however, there is significant variation amongst centers and trauma care providers in the specific medical management strategy used. This study compares antiplatelets vs. anticoagulants to determine BCVI-related stroke risk and bleeding complications to better understand the efficacy and safety of various treatment strategies. METHODS: A systematic review of MEDLINE, Embase, and Cochrane CENTRAL databases was conducted with the assistance of a medical librarian. The search was supplemented with manual review of the literature. Included studies reported treatment-stratified risk of stroke following BCVI. All studies were screened independently by two reviewers, and data was extracted in duplicate. Meta-analysis was conducted using pooled estimates of odds ratios (OR) with a random-effects model using Mantel-Haenszel methods. RESULTS: A total of 3315 studies screened yielded 39 studies for inclusion, evaluating 6552 patients (range 8 - 920 per study) with a total of 7643 BCVI. Stroke rates ranged from 0% to 32.8%. Amongst studies included in the meta-analysis, there were a total of 405 strokes, with 144 (35.5%) occurring on therapy, for a total stroke rate of 4.5 %. Meta-analysis showed that stroke rate after BCVI was lower for patients treated with antiplatelets vs. anticoagulants (OR 0.57; 95% CI 0.33-0.96, p = 0.04); when evaluating only the 9 studies specifically comparing ASA to heparin, the stroke rate was similar between groups (OR 0.43; 95% CI 0.15-1.20, p = 0.11). Eleven studies evaluated bleeding complications and demonstrated lower risk of bleeding with antiplatelets vs. anticoagulants (OR 0.29; 95% CI 0.13-0.63, p = 0.002); 5 studies evaluating risk of bleeding complications with ASA vs. heparin showed lower rates of bleeding complications with ASA (OR 0.16; 95% CI 0.04-0.58, p = 0.005). CONCLUSIONS: Treatment of patients with BCVI with antiplatelets is associated with lower risks of stroke and bleeding complications compared to treatment with anticoagulants. Use of ASA vs. heparin specifically was not associated with differences in stroke risk, however, patients treated with ASA had fewer bleeding complications. Based on this evidence, antiplatelets should be the preferred treatment strategy for patients with BCVI.

Preclinical Studies on Mechanisms Underlying the Protective Effects of Propranolol in Traumatic Brain Injury: A Systematic Review.

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity amongst trauma patients. Its treatment is focused on minimizing progression to secondary injury. Administration of propranolol for TBI maydecrease mortality and improve functional outcomes. However, it is our sense that its use has not been universally adopted due to low certainty evidence. The literature was reviewed to explore the mechanism of propranolol as a therapeutic intervention in TBI to guide future clinical investigations. Medline, Embase, and Scopus were searched for studies that investigated the effect of propranolol on TBI in animal models from inception until June 6, 2023. All routes of administration for propranolol were included and the following outcomes were evaluated: cognitive functions, physiological and immunological responses. Screening and data extraction were done independently and in duplicate. The risk of bias for each individual study was assessed using the SYCLE's risk of bias tool for animal studies. Three hundred twenty-three citations were identified and 14 studies met our eligibility criteria. The data suggests that propranolol may improve post-TBI cognitive and motor function by increasing cerebral perfusion, reducing neural injury, cell death, leukocyte mobilization and p-tau accumulation in animal models. Propranolol may also attenuate TBI-induced immunodeficiency and provide cardioprotective effects by mitigating damage to the myocardium caused by oxidative stress. This systematic review demonstrates that propranolol may be therapeutic in TBI by improving cognitive and motor function while regulating T lymphocyte response and levels of myocardial reactive oxygen species. Oral or intravenous injection of propranolol following TBI is associated with improved cerebral perfusion, reduced neuroinflammation, reduced immunodeficiency, and cardio-neuroprotection in preclinical studies.

Transperineal laser ablation of the prostate as a treatment for benign prostatic hyperplasia and prostate cancer: The results of a Delphi consensus project.

Objective: To evaluate transperineal laser ablation (TPLA) with Echolaser® (Echolaser® TPLA, Elesta S.p.A., Calenzano, Italy) as a treatment for benign prostatic hyperplasia (BPH) and prostate cancer (PCa) using the Delphi consensus method. Methods: Italian and international experts on BPH and PCa participated in a collaborative consensus project. During two rounds, they expressed their opinions on Echolaser® TPLA for the treatment of BPH and PCa answering online questionnaires on indications, methodology, and potential complications of this technology. Level of agreement or disagreement to reach consensus was set at 75%. If the consensus was not achieved, questions were modified after each round. A final round was performed during an online meeting, in which results were discussed and finalized. Results: Thirty-two out of forty invited experts participated and consensus was reached on all topics. Agreement was achieved on recommending Echolaser® TPLA as a treatment of BPH in patients with ample range of prostate volume, from <40 mL (80%) to >80 mL (80%), comorbidities (100%), antiplatelet or anticoagulant treatment (96%), indwelling catheter (77%), and strong will of preserving ejaculatory function (100%). Majority of respondents agreed that Echolaser® TPLA is a potential option for the treatment of localized PCa (78%) and recommended it for low-risk PCa (90%). During the final round, experts concluded that it can be used for intermediate-risk PCa and it should be proposed as an effective alternative to radical prostatectomy for patients with strong will of avoiding urinary incontinence and sexual dysfunction. Almost all participants agreed that the transperineal approach of this organ-sparing technique is safer than transrectal and transurethral approaches typical of other techniques (97% of agreement among experts). Pre-procedural assessment, technical aspects, post-procedural catheterization, pharmacological therapy, and expected outcomes were discussed, leading to statements and recommendations. Conclusion: Echolaser® TPLA is a safe and effective procedure that treats BPH and localized PCa with satisfactory functional and sexual outcomes.

Learning Interrupted: Educational Impact of Interruptions on Surgical Residents.

OBJECTIVE: The complex workflow of surgical residents in the workplace-based learning environment makes interruptions an unavoidable aspect of clinical work. Interruptions have been shown to affect cognitive load, surgical performance, and medical error. The purpose of this study was to describe the effects of interruptions on surgical resident education. DESIGN: Junior residents were observed by 2 trained observers using time-motion methodology between September 2018-August 2019. Interruptions were identified and coded retroactively based on predefined criteria. We captured key features of interruptions including frequency, duration, task interrupted, outcome, and learner perceived educational value. SETTING: This study took place at London Health Sciences Centre in London, Ontario, Canada, a tertiary level academic health care center associated with the Schulich School of Medicine & Dentistry at Western University. PARTICIPANTS: Junior residents on a General Surgery service were eligible for participation. Participation was voluntary. 8 residents were observed over 24 clinical periods. RESULTS: A total of 278.2 hours of resident workflow were observed, and 229 interruptions were recorded. Interruptions account for 57.9 minutes/day of a surgical resident (SD = 60.7). Interruptions occur at a frequency of 0.82 interruptions/hour. Disruptive interruptions, that interfere with the continuation or completion of the original task, occur at a frequency of 0.11 interruptions/hour. Disruptive interruptions occurred at a higher frequency of 0.34 interruptions/hour during periods of feedback, coaching and informal teaching. DISCUSSION: We observed that tasks of higher learner perceived educational value are often interrupted by tasks of lower learner perceived education value. Valuable educational experiences such as feedback, coaching and informal teaching are interrupted at a greater rate and experience disruptions at a disproportionate rate. We identified feedback, coaching and informal teaching as an education task vulnerable to disruptive interruptions that would benefit from interventions targeted toward preventing interruption. Suggested interventions include "formalizing" feedback, coaching and informal teaching.

Faculty and resident perceptions of surgical resident workload in comparison to objective data.

BACKGROUND: Little is known of the way in which stakeholders in surgical education perceive trainee workload. METHODS: A web-based survey examining the perception of current resident workload (as a percentage of daytime activities) was distributed to the faculty and residents in a Canadian general surgery residency program. The analysis compared the trainee and faculty responses against a 660-hour resident workload observation dataset. RESULTS: A total of 17 residents and 16 faculty completed the survey (74%, 67% participation). The resident estimations of workload were accurate for task categories (r = 0.91) and individual tasks (r = 0.92). The faculty estimations were accurate for task category (r = 0.90) but less so for individual tasks (r = 0.78). The residents perceived that significantly less time was allocated toward educational activities than faculty. Both of the groups underestimated the amount of time spent on indirect patient care (IPC). CONCLUSION: The faculty overestimate educational tasks as a proportion of workload. Both of the groups underestimated IPC tasks. This information can guide resident training program design and be used to bridge gaps between resident and faculty perceptions of resident workload.