The stress response to trauma and surgery

Circulating microRNA profiles are associated with acute pain and stress in castrated and tail docked lambs

Maintaining animal welfare is an essential component of animal production systems. However, multiple measurements are required to inform an animal's welfare state as there are currently no universal measurement tools. Novel biomarkers are increasingly being explored as measures of stress, pain and disease status in livestock. Here we investigate host-encoded microRNAs (miRNAs) as biomarkers of stress and pain to determine the welfare of Australian Merino sheep (Ovis aries) following castration and tail-docking. This study used samples from a retrospective trial that compared the effectiveness of pain-relief given to lambs following castration and tail-docking. Plasma collected from lambs at 0 h and 30 mins that received no pain relief post treatment were investigated. Over 1100 novel miRNAs were identified from deep sequencing of small RNA isolated from serum samples. Altered expression of 18 miRNAs was observed in lambs post-castration and tail-docking, of which one miRNA (oar-miR-1-3p) was previously characterised. A supervised machine learning model identified a five-miRNA signature that classified post-castrated and tail-docked sheep from pre-treatment with 99% accuracy. This study describes the characterisation of circulating miRNAs in Merino sheep and demonstrates that miRNAs may have utility for objective measures of animal welfare status in relation to pain.

Impact of waitlist weight change on outcomes in heart transplant recipients: a UNOS database analysis

BACKGROUND

While the effect of pre-transplant weight on patient outcomes following heart transplantation (HTx) has previously been studied, data regarding the impact of dynamic weight change prior to HTx are extremely limited.

OBJECTIVES

We sought to elucidate the interaction between HTx listing weight and weight change while waitlisted, and explore how that interaction impacts post-HTx survival in a continuous manner.

METHODS

Adult patients listed for HTx from 1987 to 2020 were identified from UNOS database. Three-dimensional restricted cubic spline analysis explored post-HTx survival relative to both changes in BMI/weight and BMI at time of HTx listing. Continuous predictor variables were analyzed with Cox proportional hazards method.

RESULTS

9,628 included patients underwent HTx. Median recipient age was 55 [IQR 46-62] years, and 21% were females. 53% of patients lost while 47% gained weight on the waitlist. Median BMI (27.6 kg/m2 [24.3-31.3] vs. 27.4 kg/m2 [24.2-30.9], paired p < 0.001) and weight (84.8 kg [73.0-98.0] kg vs. 84.4 kg [72.6-96.6], p < 0.001) were similar at listing and transplant. One-year survival was 89.3%. Weight loss over 3 BMI points or 10 kg was associated with higher hazard of death irrespective of listing BMI. In non-obese patients, some weight gain (1-4 BMI points or 5-15 kg) was associated with improved survival. In cachectic patients (BMI < 18.5), failure to gain weight was associated with worse survival.

CONCLUSIONS

Impact of weight change varies depending on listing BMI. While a survival benefit is seen in non-obese patients who gain some weight, significant weight loss is associated with poorer survival.

Copeptin Levels During Cardiac Surgery

OBJECTIVES

To investigate copeptin levels during the full perioperative course in open, adult cardiac surgery with cardiopulmonary bypass (CPB).

DESIGN

Prospective cohort study.

SETTING

A single-center study conducted in a tertiary care hospital.

PARTICIPANTS

We included 61 patients undergoing various cardiac surgical procedures. In the final analysis, 57 patients were evaluated. Patients were divided into 2 subgroups based on preoperative copeptin levels, either above or below the reference level of 10 pmol/L.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

Copeptin levels were measured at multiple time points preoperatively, perioperatively, and postoperatively. Copeptin levels significantly increased from a preoperative median of 6.6 pmol/L (interquartile range [IQR], 3.9-11.0) to 27 pmol/L (IQR, 15.0-66.0 pmol/L) after sternotomy (p ≤ 0.001). Peak levels occurred 60 minutes after CPB initiation, reaching 286 pmol/L (IQR, 163-446 pmol/L). After this, the copeptin levels did not drop significantly until CPB termination at 179.5 pmol/L (IQR, 136.0-346.0 pmol/L) (p ≤ 0.001). Subsequent decreases were observed upon arrival in the intensive care unit and throughout the postoperative period. However, at 4 days postoperatively, copeptin levels remained significantly higher (11.5 pmol/L; IQR,7.2-19.0 pmol/L; p ≤ 0.001), than preoperative levels.

CONCLUSIONS

This study describes copeptin levels during the perioperative course in adult cardiac surgery. The elevated levels during CPB suggest a strong activation of the arginine vasopressin system, with peak levels exceeding those seen in septic shock. This knowledge will enable further targeted clinical studies on copeptin as a prognostic marker in the field of cardiac surgery.

Impact of spinal anesthesia on myocardial damage, ultrastructure and cellular mechanisms in rats undergoing thoracic incision surgery

AIMS

This study aimed to investigate the impact of surgery on cardiac injury and microscopic ultrastructural changes in the heart, as well as the potential protective cellular mechanisms of spinal anesthesia.

METHODS

Male Sprague-Dawley rats were randomly assigned to four groups: Control (regular rats), Sham (received spinal saline injection), Surgery (received spinal saline followed by surgery) and Bupivacaine (received spinal bupivacaine 0.5 %, 50 μL followed by surgery), and Bupivacaine (received spinal bupivacaine 0.5 %, 50 μL followed by surgery). The serum and hearts of the rats were assessed for troponin I, NT-proBNP, electron microscopy, catecholamines, markers of oxidative stress and endoplasmic reticulum stress, as well as apoptosis and autophagy.

RESULTS

After surgery, the hearts showed signs of injury, with decreased tissue troponin I and elevated NT-proBNP levels. Electron microscopy revealed mitochondrial swelling, disarrangement and cytosolic vacuoles. Serum epinephrine levels and expression of β1 and β2 adrenergic receptors were elevated. Serum nitrate and nitrite levels (markers of oxidative stress), along with the ER stress indicator GRP78 and autophagy indicators LC3 and LAMP-1, were heightened, and cardiomyocyte apoptosis increased. These effects can be mitigated with the use of spinal bupivacaine.

CONCLUSIONS

Surgery can cause ultrastructural and cellular damage, elevate sympathetic activity, oxidative stress, and endoplasmic reticulum stress, leading to autophagy and cardiomyocyte apoptosis. Spinal anesthesia can protect the heart from these injuries.

Assessing high-risk perinatal complications as risk factors for postpartum mood disorders

OBJECTIVES

Postpartum mood disorders affect approximately 20 % of postpartum women. This study examines the association between postpartum mood disorders and preeclampsia with severe features (SPE), postpartum hemorrhage (PPH), very/extremely preterm delivery (EPTD), and fetal congenital malformations (FCM).

METHODS

A retrospective chart review was conducted at a large southeastern quaternary academic hospital using ICD-10 codes for the four high-risk perinatal complications. Medical records included 3,652 cases and 750 normal patient comparisons (NPC). Inclusion criteria: 1) prenatal visit at the institution, 2) live delivery at the institution, 3) postpartum visit at the institution, and 4) completed Edinburgh Postnatal Depression Scale (EPDS) at postpartum visit. EPDS scores≥12 and EPDS-3A scores≥5 were considered positive for depression and anxiety symptoms, respectively.

RESULTS

Five cohorts were analyzed [NPC (n=200), SPE (n=150), PPH (n=153), EPTD (n=102), and FCM (n=200)]. Independent sample t-tests revealed significant differences in mean EPDS scores between NPC and EPTD (p<0.001) and FCM (p=0.014) and in mean EPDS-3A scores between NPC and EPTD (p<0.001) and PPH (p=0.011).

CONCLUSIONS

EPTD, FCM, and PPH are diagnoses associated with elevated EPDS and/or EPDS-3A scores. Increased mood surveillance in patients with these complications is warranted. Understanding the association of these conditions with increased depression and anxiety symptoms will allow for earlier identification and treatment of postpartum mood disorders.

The immune-inflammatory responses on the hypothalamic-pituitary-adrenal axis and the neurovascular unit in perioperative neurocognitive disorder

Perioperative neurocognitive disorders (PNDs) refer to a wide spectrum of cognitive impairment persisting days to even after a year postoperative with significant morbidity and mortality. However, despite much efforts involving perioperative managements, PNDs are still prevalent with no standard preventative and therapeutic strategy. To overcome PNDs, a better understanding of pathophysiology of PNDs is crucial and a large number of studies have proven that immune-inflammatory responses from surgical stress are involved in the abnormal activation of the hypothalamic-pituitary-adrenal (HPA) axis and destabilization of neurovascular unit (NVU) that lead to PNDs. The HPA axis is one of the key components to maintaining physiological homeostasis in response to stress. Under normal conditions, the HPA axis is involved in multiple roles from memory consolidation to regulating the circadian rhythm by activating adrenal cortex to secret cortisol. However, when overwhelmed with inflammatory response from surgical stress, HPA axis may be abnormally activated to release excessive glucocorticoids to cause PNDs. In addition, NVU, the functional unit of the brain essential for maintaining blood brain barrier and cerebral blood flow, is another possible factor that may lead to PNDs as compromised NVU from inflammatory response can result in disrupted blood brain barrier and impaired brain homeostasis. Therefore, the interaction of immune-inflammatory response with the HPA axis and the NVU seems to play a significant role and therapeutic and/or preventive strategies focused on these interactions may be promising direction for future managements of PNDs.

Inflammatory response and short-term outcomes after laparoscopic versus robotic transabdominal preperitoneal inguinal hernia repair: randomized clinical trial (ROLAIS)

BACKGROUND

The aim of this study was to compare robotic-assisted transabdominal preperitoneal (R-TAPP) and conventional laparoscopic transabdominal preperitoneal (L-TAPP) inguinal hernia repair with respect to surgical stress response and short-term outcomes.

METHODS

This single-centre, open-label, RCT enrolled patients undergoing elective inguinal hernia repair. Patients were randomized 1 : 1 to R-TAPP or L-TAPP using a computer-generated sequence with block sizes of six. All procedures were performed by the same experienced surgeons. The primary outcome was plasma C-reactive protein (CRP) levels. Secondary outcomes included interleukin 6 (IL-6) levels, operating time, complications, length of stay, and readmission rate.

RESULTS

A total of 150 patients (R-TAPP, 76; and L-TAPP, 74) were randomized, with 11 withdrawing before surgery, leaving 139 (R-TAPP, 74; and L-TAPP, 65) for intention-to-treat analysis. CRP levels were significantly lower after R-TAPP on postoperative days 1 and 3 (reductions of 23% and 32% respectively, P = 0.001). IL-6 levels were also lower after R-TAPP at 30 and 120 min after extubation (reductions of 26% and 22% respectively, P < 0.001). R-TAPP was associated with a shorter operating time (-13.4 min, P < 0.001), fewer complications (23.0% versus 41.5%, P = 0.029), including fewer haematomas (6.8% versus 18.5%, P = 0.043), and a higher same-day discharge rate (95.9% versus 81.5%, P = 0.012). No significant differences were observed regarding chronic pain and recurrence rates.

CONCLUSION

R-TAPP was associated with reduced surgical stress, complications, operating time, and hospitalization compared with L-TAPP. These findings support further multicentre trials to assess long-term outcomes and generalizability.

REGISTRATION NUMBER

NCT05839587 (http://www.clinicaltrials.gov).

Frailty and Intrinsic Capacity as Predictors of Recovery in Older Patients Surgically Treated for Cancer: A Longitudinal Study

BACKGROUND

Advanced age, cancer, and surgery contribute to functional decline, with concurrent cancer and surgery exacerbating this decline due to slower recovery and adverse outcomes.

OBJECTIVE

To investigate the association between preoperative frailty and intrinsic capacity and postoperative functional recovery and quality of life in older patients surgically treated for cancer.

METHODS

This longitudinal study at a tertiary care medical center included 74 patients 75 years and older undergoing elective surgery for malignancies, excluding those with terminal-stage cancer. Data on demographic variables, Cumulative Illness Rating Scale for Geriatrics, Clinical Frailty Scale, and intrinsic capacity were collected at admission. The Minimum Data Set Activities of Daily Living (MDS-ADL) and EuroQoL 5-dimension 3-level questionnaire (EQ5D) were assessed at admission, after operation, and 1 month, 3 months, 6 months, and 1 year after the operation for cancer.

RESULTS

The mean age of the 74 participants was 80.3 ± 4.6 years, and 56.8% were female. The generalized estimating equation showed that an increased preoperative Clinical Frailty Scale score was significantly associated with worsened MDS-ADL (adjusted β = 1.25; 95% confidence interval = 0.39-2.11; P = .004) and decreased EQ5D score after surgery for cancer (adjusted β = -0.04; 95% confidence interval = -0.07 to -0.01; P = .004). No significant associations were observed between intrinsic capacity and postoperative MDS-ADL or EQ5D scores.

CONCLUSION

This study demonstrated that frailty is a better predictor of postoperative functional recovery and quality of life than intrinsic capacity in older cancer patients.

IMPLICATIONS FOR PRACTICE

Identifying frailty preoperatively can help healthcare providers better anticipate recovery challenges and tailor postsurgical care to improve outcomes.

The Role of Inflammation in Cancer: Mechanisms of Tumor Initiation, Progression, and Metastasis

Inflammation is an essential component of the immune response that protects the host against pathogens and facilitates tissue repair. Chronic inflammation is a critical factor in cancer development and progression. It affects every stage of tumor development, from initiation and promotion to invasion and metastasis. Tumors often create an inflammatory microenvironment that induces angiogenesis, immune suppression, and malignant growth. Immune cells within the tumor microenvironment interact actively with cancer cells, which drives progression through complex molecular mechanisms. Chronic inflammation is triggered by factors such as infections, obesity, and environmental toxins and is strongly linked to increased cancer risk. However, acute inflammatory responses can sometimes boost antitumor immunity; thus, inflammation presents both challenges and opportunities for therapeutic intervention. This review examines how inflammation contributes to tumor biology, emphasizing its dual role as a critical factor in tumorigenesis and as a potential therapeutic target.

Inflammatory Markers and Postoperative New-Onset Atrial Fibrillation: Prognostic Predictions of Neutrophil Percent to Albumin Ratio in Patients with CABG

Background/Objectives: Postoperative new-onset atrial fibrillation (AF) (PNOAF) is the most common complication after coronary artery bypass graft (CABG), and its incidence has been reported as up to 50% in studies. In this study, we investigated whether there was a relationship between PNOAF and the neutrophil percentage to albumin ratio (NPAR) levels after on-pump CABG. Methods: A total of 454 patients who underwent CABG were included in the study. NPAR was calculated by dividing the neutrophil count by the albumin value. Results: It was determined that 93 patients developed PNOAF (20.4%). When the patient groups that developed and did not develop PNOAF were compared in terms of laboratory findings, C-reactive protein (CRP) values (4.0 mg/L (2.8-7.9) vs. 2.9 mg/L (1.1-6.7), <0.001), neutrophil/lymphocyte ratio (NLR) (2.2 (1.2-4.2) vs. 1.4 (0.7-3.1), <0.001), platelets-to-lymphocyte ratio (112 (72-177) vs. 92 (69-122), <0.001) and NPAR (2.29 (1.68-3.8) vs. 1.09 (0.79-1.81), <0.001), were found to be statistically significantly higher in the group that developed PNOAF. ROC analysis showed that the cut-off value for NPAR for the development of PNOAF was 1.86 with 78% sensitivity and 72% specificity (area under the ROC curve = 0.778, 95% CI (0.728-0.828), p < 0.001). Conclusions: NPAR, which can be detected by a simple venous blood test, has shown a strong predictive value for PNOAF in patients with CABG.

Anesthetic considerations in cancer care

PURPOSE OF REVIEW

Cancer burden remains a global medical and financial challenge. Advances in surgical management have resulted in increased oncological surgeries that often involve anesthetic administration. This review aims to inform on anesthetic considerations when caring for cancer patients in the perioperative period.

RECENT FINDINGS

There are various retrospective studies and, more recently, several randomized controlled trials that have explored whether the choice of anesthesia (total intravenous anesthesia vs. inhaled anesthetic) results in a significant difference in cancer outcomes, mortality, cancer recurrence, and metastasis. To date, no definitive proof has been made, and the current conclusion remains that the anesthetic technique does not influence survival or overall long-term outcomes.

SUMMARY

Comprehensive risk assessment is essential in cancer patients before elective surgeries due to a variety of concerns such as malnutrition, aspiration risk, postradiation airway compromise, and antineoplastic systemic effects. Oncologic patients' exposure to chemotherapy and radiation causes immunosuppression and multiorgan toxicity that places them at increased perioperative risk for morbidity and mortality. Other concerns include the challenges of adequate pain management and pre-existing chronic pain.

Prehabilitation Interventions in Patients Undergoing Colorectal Cancer Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Surgical resection is the primary treatment modality for colorectal cancer. Prehabilitation is about enhancing the patient's physiological capacity preoperatively to reduce the risk of treatment-related complications. Clear definitions of the modality, content, and duration of prehabilitation, including its components such as nutrition, exercise, and psychological support, are lacking. Some review articles have proposed that a multimodal approach may yield the best overall outcomes, but the clinical efficacy of such an approach requires further exploration.

OBJECTIVE

This study consisted of a systematic review and meta-analysis to investigate the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery.

METHODS

We searched PubMed, Embase, CINAHL, and the Cochrane Library from inception to August 5, 2023, without language or publication period restrictions. The included studies were randomized controlled trials, prospective studies, or retrospective studies that examined the effectiveness of multimodal prehabilitation programs for patients undergoing colorectal surgery. A random-effects model was used for data analysis.

RESULTS

This study included 14 articles that analyzed data from 2314 patients who underwent colorectal cancer surgery. In comparisons against a control group, multimodal prehabilitation significantly reduced the length of hospital stay ([mean difference; MD] = -2.47 days, 95% confidence interval [CI] [-3.56, -1.39]), postoperative complication rate (odds ratio; [OR] = 0.74, 95% CI [0.59, 0.94]), and time to the first passage of flatus (MD = -0.43 days, 95% CI [-0.66, -0.20]).

CONCLUSION

Multimodal prehabilitation interventions before colorectal cancer surgery reduce hospital stay lengths, lower complication rates, and promote bowel recovery, particularly in older populations.

Anesthetic Management for Proximal Aortic Repair

Surgical repair of the proximal aorta is a complex endeavor, requiring cardiopulmonary bypass (CPB) and often the use of hypothermic circulatory arrest (HCA). In addition to the normal considerations for patients undergoing cardiopulmonary bypass, additional challenges include cerebral and end-organ protection during periods of circulatory arrest. This review aims to provide an up-to-date, evidence-based review on anesthetic management for proximal aortic repair.

Comparison of outcomes after total hip arthroplasty in hip fracture versus elective cases in patients over 60 years of age

Background

Total hip arthroplasty (THA) allows for the replacement of impaired parts of the hip joint with artificial ones. This study aimed to compare the differences in preoperative patient profiles, postoperative complications, and clinical outcomes of two patient groups: those who underwent THA for fractures and those who underwent THA electively for diseases such as osteoarthritis (OA) and avascular necrosis (AVN).

Methods

We retrospectively analyzed the data of patients who underwent THA between March 2012 and December 2021. Of 232 patients, 173 patients who met the exclusion and inclusion criteria were included. Patients were divided into two groups (Group 1: 113 patients diagnosed with OA or AVN; Group 2: 60 patients diagnosed with hip fracture). Pre- and postoperative Visual Analogue Scale (VAS), Koval scores, and postoperative modified Harris Hip Score (mHHS) were used to assess clinical outcomes. Demographic data and postoperative complications of the two groups were compared. After surgery, a rehabilitation protocol was initiated.

Results

Patients in Group 2 (fracture) had more preoperative comorbidities than those in Group 1 (elective). Follow-up months are 26.22 ± 19.78 (Group 1), and 27.42 ± 17.02 (Group 2) respectively (P > 0.05). There were no statistical differences in the prevalence of postoperative complications between two groups (P > 0.05). Compared with Group 1(elective), Group 2(fracture) showed lower VAS (P < 0.01) at last follow-up, and no difference in Koval score (P = 0.77) and mHHS (P = 0.96) at last follow-up.

Conclusion

Considering the characteristics of the two groups and their perioperative multidisciplinary care, THA for hip fractures can provide good clinical results compared to those with elective THA.

Perioperative oxygen administration for adults undergoing major noncardiac surgery: a narrative review

Perioperative oxygen administration, a topic under continuous research and debate in anesthesiology, strives to optimize tissue oxygenation while minimizing the risks associated with hyperoxia and hypoxia. This review provides a thorough overview of the current evidence on the application of perioperative oxygen in adult patients undergoing major noncardiac surgery. The review begins by describing the physiological reasoning for supplemental oxygen during the perioperative period and its potential benefits while also focusing on potential hyperoxia risks. This review critically appraises the existing literature on perioperative oxygen administration, encompassing recent clinical trials and meta-analyses, to elucidate its effect on postoperative results. Future research should concentrate on illuminating the optimal oxygen administration strategies to improve patient outcomes and fine-tune perioperative care protocols for adults undergoing major noncardiac surgery. By compiling and analyzing available evidence, this review aims to provide clinicians and researchers with comprehensive knowledge on the role of perioperative oxygen administration in major noncardiac surgery, ultimately guiding clinical practice and future research endeavors.

Thiol/Disulfide Homeostasis in Pericardial Fluid and Plasma of Patients Undergoing Coronary Artery Bypass Surgery

INTRODUCTION

On-pump coronary artery bypass grafting (CABG) method affect almost allbiochemicalreactions by disrupting the patient's redox homeostasis. Detection of systemic redox hemostasis in the patient is critical for the CABG method's success and the prognosis of the disease. In this study, thiol/disulfide parameters, which are indicators of redox homeostasis, and ischemia-modified albumin levels in the plasma and pericardial fluid of patients who underwent CABG were investigated.

METHODS

Sixty patients who underwent an on-pump CABG operation with the cardiopulmonary bypass method were included in this study. Blood samples were taken from the patients before and after cardiopulmonary bypass. Pericardia fluid samples were taken before cardiopulmonary bypass. Then, thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels in the pericardial fluid and the patients' plasma levels were compared.

RESULTS

Albumin and ischemia-modified albumin levels were significantly higher in the postoperative period compared to the preoperative one (P<0.001). Thiol/disulfide parameters were higher and statistically significant in preoperative than in postoperative examinations (P<0.001). A negative correlation was found between pericardial fluid ischemia-modified albumin and thiol-disulfide parameters (P<0.001).

CONCLUSION

Changes in thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels at different times during the on-pump CABG may be caused by foreign non-endothelial surfaces, filters, the reperfusion process, and pharmacological effects in the extracorporeal circulation. Thiol/disulfide homeostasis, albumin, and ischemia-modified albumin levels should be monitored during the on-pump CABG and should be intervened with appropriate therapeutic strategies. In this way, secondary pathologies can be avoided by preventing cellular damage and excessive inflammatory responses.

Minimally Invasive vs. Open Synovectomy in Rheumatoid Arthritis: Insights into Clinical Recovery, Systemic Inflammation, and Economic Impact

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by persistent synovial inflammation, leading to joint destruction and disability. Synovectomy, the surgical removal of inflamed synovial tissue, is performed when pharmacological treatments are insufficient. This study compares the clinical efficacy, systemic inflammatory response, and cost-effectiveness of minimally invasive arthroscopic synovectomy versus traditional open synovectomy in RA patients. Methods: A comparative observational study was conducted on 53 RA patients undergoing either arthroscopic (n = 30) or open synovectomy (n = 23) at "Pius Brînzeu" Timișoara County Emergency Clinical Hospital over nine years. Clinical outcomes, including pain relief (VAS), functional improvement (HAQ), complication rates, and recovery times, were assessed at baseline, 1, 3, 6, and 12 months postoperatively. Systemic inflammatory markers (CRP, IL-6, TNF-α, ESR, and fibrinogen) were measured preoperatively, at 48 h and 30 days postoperatively. A cost-effectiveness analysis evaluated direct and indirect healthcare costs. Results: Arthroscopic synovectomy demonstrated significantly faster pain reduction and functional recovery within the first three months (p < 0.001), shorter hospital stays (3.1 vs. 6.4 days, p < 0.001), and quicker returns to daily activities (14.5 vs. 22.3 days, p < 0.001) compared to open synovectomy. Inflammatory markers were significantly lower postoperatively in the arthroscopic group (p < 0.01), indicating reduced systemic inflammation. Complication rates were markedly lower in the arthroscopic group (26.66% vs. 82.60%, p < 0.001). Despite higher procedural costs, arthroscopic synovectomy proved more cost-effective due to reduced hospitalization and faster recovery. Conclusions: Arthroscopic synovectomy offers superior early postoperative outcomes, reduced systemic inflammation, and greater cost-effectiveness compared to open synovectomy, with comparable long-term joint stability. These findings support its preference as the surgical technique of choice for RA patients requiring synovectomy.

Development of a predictive model for post-surgical chronic pain: a retrospective analysis of calcaneal fracture patients

BACKGROUND

Chronic pain following calcaneal fracture surgery substantially diminishes patients' quality of life, yet effective risk prediction tools remain scarce. This study aimed to develop and validate a reliable predictive model for assessing the risk of chronic pain development after calcaneal fracture surgery.

METHODS

This retrospective analysis examined 398 patients who underwent calcaneal fracture surgery between January 2022 and July 2023. Patients were randomly allocated into model development (n = 280) and validation (n = 118) cohorts. Independent risk factors were identified through multivariate logistic regression analysis to construct the prediction model. Model performance was evaluated using the area under the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis.

RESULTS

The study identified several independent predictors of postoperative chronic pain: body mass index (BMI) (OR:1.10, 95%CI:1.02-1.19, P = 0.014), operative duration (OR:1.01, 95%CI:1.00-1.02, P = 0.019), surgical approach, and Böhler angle (OR:1.03, 95%CI:1.00-1.06, P = 0.025). The predictive model demonstrated good discriminative ability in both development and validation cohorts, with AUC values of 0.691 (95%CI:0.63-0.75) and 0.655 (95%CI:0.56-0.77), respectively. Calibration plots showed strong agreement between predicted probabilities and observed outcomes.

CONCLUSION

Our newly developed predictive model, incorporating BMI, operative duration, surgical approach, and Böhler angle, effectively predicts the risk of chronic pain following calcaneal fracture surgery. This tool provides valuable guidance for clinicians in conducting individualized risk assessments and implementing targeted preventive strategies.

Photoplethysmography parameters in monitoring nociception during general anesthesia

BACKGROUND

Validated monitoring methods for evaluating the balance of nociception and anti-nociception (BNAN) are needed in general anesthesia. This study assessed six photoplethysmography (PPG) parameters, computed from finger photoplethysmographic waveforms in patients undergoing gynecological surgery under general anesthesia.

METHODS

A total of 20 participants were included, each undergoing general anesthesia with propofol and remifentanil. The same concentration of remifentanil was maintained throughout the experiment, four different intensities of electrical stimulation were administered, and the patient's fingertip PPG was meticulously recorded. PPG data were preprocessed to extract six PPG morphological parameters, and photoplethysmographic amplitude (PPGA), pulse beat interval (PBI), and surgical pleth index (SPI). Receiver operating characteristic (ROC) curves and the Area Under the Curve (AUC) were constructed and calculated to accurately measure its ability to reflect the nociceptive stimulus state. The consistency of different phase parameters at different stimulus intensities was evaluated by calculating the prediction probabilities. All results were compared with those obtained using SPI, PPGA, and PBI.

RESULTS

After stimulation, all parameters and SPI showed significant changes compared with those before stimulation (p = 0.000). The catacrotic phase parameters (AC and MHC) showed higher discrimination in adequate analgesia and congruence with electrical stimulation intensity than the overall phase parameters, PPGA, and anacrotic phase parameters (AC: AUC = 0.851, Pk = 0.800; MHC: AUC = 0.837, Pk = 0.792).

CONCLUSIONS

In this study, six PPG morphological parameters were proposed and observed for the first time to effectively distinguish the occurrence of nociception. Compared with the overall phase parameters, PPGA, and anacrotic phase parameters, catacrotic phase parameters were more capable of characterizing noxious stimuli and more consistent with changes in electrical stimulation intensity.

TRIAL REGISTRATION

ChiCTR2200062228; Registered at http://clinicaltrials.gov on July 30, 2022.

High risk of short-term mortality and postoperative complications in patients with generalized peritonitis undergoing major emergency abdominal surgery-a cohort study

BACKGROUND

Secondary generalized peritonitis is a potentially life-threatening condition. The aim of this study was to investigate the association between secondary generalized peritonitis and short-term mortality and postoperative complications in patients undergoing major abdominal emergency surgery.

METHODS

The study included patients with the age ≥ 18 years undergoing major emergency abdominal surgery in a University Hospital from 2017 to 2019 after the introduction of a perioperative bundle care program. The primary outcome measures were short-term mortality, defined as death within 30 and 90 days after surgery and postoperative complications within 30 days after surgery. Uni- and multivariable logistic regression analyses were performed to evaluate risk factors for 30- and 90-days mortality and 30-days postoperative complications.

RESULTS

A total of 591 patients were included, of whom 21% (124/591) had generalized peritonitis. The overall 30 day-mortality rate was 12.5% (74/591). Patients with generalized peritonitis had a significantly higher 30-day mortality rate than patients with non-generalized peritonitis 18.5% (23/124) vs. 10.9% (51/467), P = 0.033. Generalized peritonitis was an independent risk factor for 30- and 90- days mortality. There was a significantly higher rate of admission to ICU for patients with generalized peritonitis 39.5% (49/124) vs. 12.6% (59/467), P < 0.001. Patients with generalized peritonitis had significantly higher rates of surgical and non-surgical complication compared to patients with non-generalized peritonitis 87.1% (108/124) vs. 65.7% (307/467), P < 0.001. Generalized peritonitis was an independent risk factor of 30 days postoperative complications.

CONCLUSION

In a population undergoing major emergency abdominal surgery treated in a perioperative optimization protocol, generalized peritonitis was an independent risk factor for both 30- and 90-days mortality and postoperative complications.

A randomised trial to assess the impact of midodrine on early mobilisation after elective primary hip replacement surgery

Early mobilisation following elective total hip arthroplasty (THA) facilitates quicker rehabilitation, and reduces complications and hospital length of stay. Reasons for delayed mobilisation are multifactorial, but the most common cause is orthostatic intolerance. Midodrine, an oral alpha-1 agonist, is used off-label for perioperative hypotension. However, there are few randomised trials assessing its use in the perioperative setting to improve patient outcomes. The aim of the study was to determine whether midodrine improves early mobilisation following primary THA, and whether this relates to reduced orthostatic intolerance. This prospective, triple-blinded, multicentre study involved 42 patients randomised to either placebo or 20 mg midodrine, 2 h before physiotherapy, on Day 1 postoperatively. The inclusion criteria were adults undergoing elective unilateral THA under spinal anaesthesia. The primary endpoint was the ability to walk 5 m with physiotherapists. Secondary endpoints included the incidence of orthostatic intolerance and hypotension. A preplanned interim analysis showed no statistical difference in ability to mobilise 5 m (78.26% vs 78.95%, P = 1.0). There was no statistically significant difference in the incidence of orthostatic intolerance between the groups 17.4% vs 31.6% (P = 0.45). Pre-emptive use of midodrine did not improve patient mobilisation the morning after elective primary THA and had no significant effect on the incidence of orthostatic hypotension.

Efficacy and safety of massage for postoperative stress in colorectal cancer patients: a randomized, controlled, three-arm trial

Purpose

The purpose of this study was to investigate the effect of rhythmic embrocation (RE), a massage technique, on postoperative stress levels (measured by heart rate variability) in colorectal cancer surgery patients compared to empathic conversation.

Methods

The study included 68 patients who were randomized into three groups: one received RE from professionals, another from students, and the third received empathic conversations. Stress was quantified using heart rate variability before and after the interventions.

Results

The standard deviation of the heartbeat intervals (SDNN) increased more in the professional RE group 9.12 ms (IQR 3.59-12.3 ms) than in the other groups: student RE group 5.68 ms (-0.66-7.5 ms), empathic conversation group 6.64 ms (-1.49-7.38 ms); hence stress decreased more in the professional RE group, although not statistically significant (p= 0.21). Other factors like sleep quality, nausea, pain, and mood did not differ significantly between the groups. No complications were associated with the interventions.

Conclusion

RE was safe and a statistically significant superiority of RE on postoperative stress compared to empathic conversations could not be found. Due to high inter- and intraindividual variability a clear pattern of response of the secondary outcomes to RE in comparison to empathic conversations could not be found. The study was limited by a small sample size, high patient variability, effective co-interventions for sleep, pain and nausea, and by an imbalance between groups. The study indicates that future research on RE should focus on a more narrowly defined patient population, increase the sample size, and select comparison groups that are clearly distinct from each other as well as a clinical context with fewer confounding factors. Furthermore, the patient's preferences and previous experiences with massage therapy should be considered.

Clinical trial registration

German Clinical Trials Register (www.drks.de), identifier DRKS00023407.

Postoperative oliguria after intermediate and high-risk surgeries in critical care, A cohort analysis

INTRODUCTION

Oliguria is commonly used as a cutoff for acute kidney injury (AKI), however, a decrease in urine output is common during surgery and may represent an adaptative response in the perioperative setting rather than a reduction in glomerular filtration rate, leading to a possible overestimation of postoperative AKI incidence. Although this dilemma has been addressed in the intraoperative scenario, the incidence and impact of oliguria in the first postoperative day represents a gap in the current literature. Our main goal is to describe the incidence, risk factors and clinical outcomes related to postoperative oliguria.

METHODS

This was a retrospective cohort conducted in four intensive care units (ICUs) across two private Brazilian hospitals, analyzing patients admitted after intermediate and high-risk surgeries between January 1, 2018 and December 31, 2022.

RESULTS

1476 patients were included in the final analysis. Overall, 656 (44,5 %) were males, and the median age was 61,7 years. Oliguria was identified in 508 (34,4 %) patients within the first 24 h after surgery. Vasopressor requirement at admission, non-elective procedures, male sex and baseline serum creatinine were higher among oliguric patients. Among oliguric patients, age and basal serum creatine were higher among those who experienced AKI. Although only 12,4 % of oliguric patients developed AKI according to serum creatinine criterion, this incidence was significantly higher than in non-oliguric group (3,6 %), RR 3.42, IC 95 % 2.3-5.1 (p < 0.01). AKI recovery, RRT, ICU and hospital free days, and mortality were similar between the groups.

CONCLUSIONS

Postoperative oliguria is common after intermediate and high-risk surgical procedures and increases the risk of AKI. However, oliguria was largely unrelated with kidney disfunction measured by serum creatinine (87,6 %), raising doubts on whether diuresis overestimates AKI incidence in the postoperative setting.

Optimisation of the patient having oncological surgical through prehabilitation: a narrative review

INTRODUCTION

Prehabilitation aims to improve physiological reserve and psychological resilience, enabling patients to better tolerate the physiological stress of major surgery, thereby reducing the risk of complications and improving surgical outcomes. In this review, we provide an update of the development of prehabilitation in patients having cancer surgery.

METHODS

We searched databases of peer-reviewed research to identify appropriate papers. Keywords comprised 'prehabilitation', 'cancer surgery' and associated synonyms (prehab; pre-operative rehabilitation; cancer). The results were combined with articles identified by reviewing the references of key papers and the use of the grey literature to develop our discussion.

RESULTS

We detail the different elements of prehabilitation (exercise, nutrition, psychological support) relevant to patients with cancer undergoing surgery, focusing on the recent evidence base and ongoing challenges. Within this, we consider the role of behaviour change in enabling patients to undertake prehabilitation interventions and reflect on the different models of prehabilitation that have been utilised. Facilitators and barriers to implementation of prehabilitation are explored. Key findings include positioning prehabilitation as an integral part of the oncological surgical pathway which includes, but is discrete from, medical optimisation.

DISCUSSION

Prehabilitation has the potential to improve surgical outcomes for patients undergoing cancer surgery. Further evidence is needed to understand how and what we provide to patients as optimal exercise, nutrition and psychological interventions as part of their surgical care, and how we improve long-term lifestyle using behaviour change methodology. Digital technology offers the opportunity for scaling and greater personalisation of prehabilitation but needs to be deliberately fashioned to ensure equitable access.

Euglycemic Ketoacidosis Associated with SGLT-2 Inhibitors in Non-diabetic Patients-A Narrative Review

Euglycemic ketoacidosis is an acute, life-threatening emergency that is characterized by euglycemia, metabolic acidosis, and ketonemia. It is a well-recognized adverse event in diabetic patients taking sodium-glucose cotransporter-2 inhibitor (SGLT-2 inhibitor). However, there is limited data on SGLT-2 inhibitor-related euglycemic ketoacidosis in non-diabetic patients. The mechanism behind SGLT-2 inhibitor-associated euglycemic ketoacidosis involves a general state of starvation or relative insulin deficiency, which exacerbates the mild baseline ketonemia caused by this class of medications while normoglycemia is maintained. The incidence of euglycemic ketoacidosis will likely increase with the increasing use of SGLT-2 inhibitors for various indications in addition to diabetes mellitus type 2, predominantly for congestive heart failure (CHF). Recognizing the signs and symptoms of this life-threatening condition is essential to treat it effectively. Our objective is to comprehensively revisit the pathophysiology of euglycemic ketoacidosis associated with SGLT-2 inhibitors and the risk factors for the condition, review the available data, and summarize the reported cases of euglycemic ketoacidosis in non-diabetic patients on SGLT-2 inhibitors. Our literature search identified five articles with six cases of euglycemic ketoacidosis in non-diabetic patients who were on SGLT-2 inhibitors for heart failure with reduced ejection fraction. The common risk factor in five out of the six cases was decreased oral intake due to acute illness, fasting, or a perioperative state.

A New Surgical Concept for the Efficient Treatment of Large and Deep Burns

Effective burn surgery is based on two fundamental principles: prompt excision of necrotic tissue and definitive coverage, preserving functional dermis and body contour. There is often compromise, either prioritizing the urgency of excision or opting for patient stability and optimal conditions prior to autografting. We propose a surgical concept that addresses this critical treatment gap. In 2022, we implemented a new three-phase protocol, EDM: (Excision phase, E) Immediate excision of the burn wound preserving body contour; (Dermis phase, D) definitive temporization of the wound bed, using biodegradable temporizing matrix, to prepare it for successful grafting. Upon complete dermal temporization, full autologous coverage in a single micrografting procedure is achieved (Meek phase, M). We performed a retrospective single-center cohort study to characterize the EDM protocol compared to the prior standard of care (>40% TBSA, n = 5 in EDM vs n = 10 matched controls). Primary outcomes were total surgeries required, total surgeries to achieve>90% healing, uninterrupted recovery time without surgery, and time on mechanical ventilation. The EDM group required fewer surgeries in total (5 vs 9.5; P = .01) and to achieve>90% healing (3 vs 6.5; P = .001). EDM patients experienced longer uninterrupted recovery (25 vs 13 days, P = .001). Additionally, EDM patients spent less time on mechanical ventilation (210 vs 1136 h, P = .005). The EDM protocol could improve surgical efficiency, ultimately having the potential to expedite rehabilitation for severely burned patients. The study underscores the potential of combining the fundamentals of burn surgery, with innovative surgical techniques and materials, in order to bridge the gap between excision and grafting.

Endocrine and metabolic alterations in response to systemic inflammation and sepsis: a review article

Severe sepsis is cognate with life threatening multi-organ dysfunction. There is a disturbance in endocrine functions with alterations in several hormonal pathways. It has frequently been linked with dysfunction in the hypothalamic pituitary-adrenal axis (HPA). Increased cortisol or cortisolemia is evident throughout the acute phase, along with changes in the hypothalamic pituitary thyroid (HPT) axis, growth hormone-IGF-1 axis, insulin-glucose axis, leptin, catecholamines, renin angiotensin aldosterone axis, ghrelin, glucagon, hypothalamic pituitary gonadal (HGA) axis, and fibroblast growth factor-21. These changes and metabolic alterations constitute the overall response to infection in sepsis. Further research is essential to look into the hormonal changes that occur during sepsis, not only to understand their potential relevance in therapy but also because they may serve as prognostic indicators.

Systemic inflammatory response index improves prognostic predictive value in intensive care unit patients with sepsis

Sepsis is a severe infectious disease with high mortality. However, the indicators used to evaluate its severity and prognosis are relatively complicated. The systemic inflammatory response index (SIRI), a new inflammatory indicator, has shown good predictive value in chronic infection, stroke, and cancer. The purpose of this study was to investigate the connection between sepsis and SIRI and evaluate its predictive usefulness. A total of 401 patients with sepsis were included in this study. Multiple linear regression and logistic regression analyses were performed to evaluate the relationship between SIRI and sepsis. The restricted cubic spline (RCS) method was employed to illustrate the dose-response relationship. The area under the curve (AUC) and decision curve analysis (DCA) were used to evaluate the prognostic value of SIRI. Multiple linear regression analysis revealed a significant positive correlation between SIRI and both blood cell count and Sequential Organ Failure Assessment (SOFA) score. Additionally, higher SIRI levels were significantly linked to a higher risk of sepsis worsening, according to logistic regression analysis. The RCS curve demonstrated that the risk of poor prognosis rose with increasing SIRI, particularly when SIRI exceeded 6.1. Furthermore, AUC and DCA results showed that SIRI had superior predictive value compared to traditional indicators. A higher SIRI is linked to a worse prognosis and more severe sepsis. SIRI may serve as a novel prognostic indicator in sepsis, though further clinical studies are necessary to confirm these findings.

Postmortem study of adrenomedullin and cortisol in femoral serum and pericardial fluid related to acute pulmonary edema

Currently, various tools aid in determining the cause of death and the circumstances surrounding it. Thanatochemistry is one such method that provides insights into the physiopathological mechanisms of death and the behavior of specific biomarkers in different body fluids postmortem. Certain biomarkers, characterized by their stability and specificity to vital tissues like the lungs, are associated with mechanisms contributing to death, such as acute pulmonary edema (APE). This study aims to analyze the behavior of midregional pro-adrenomedullin (MR-proADM) and cortisol levels, measured in pericardial fluid and femoral serum, in relation to the severity of APE, categorized according to specific criteria. Samples were collected from a total of 92 corpses (77 males, 15 females) with a mean age of 56.7 ± 15.2 years. The severity of APE associated with the deaths was classified into three groups: slight or absent (n = 7; 8.6%), medium or moderate (n = 16; 19.8%), and intense (n = 58;71.6%).The determination of MR-proADM and cortisol levels was conducted using ELISA kits and an Immunoassay Analyzer, respectively. Our results reveal a significant increase in MR-proADM concentration with the severity of APE. Furthermore, a correlation was established between cortisol and MR-proADM concentrations in both pericardial fluid and femoral serum samples. This indicates that the severity of APE influences the production of ADM, regardless of the specific underlying pathophysiological mechanisms. Cortisol values were also found to be higher in the intense APE group compared to the moderate group.This study contributes to our understanding of the relationship between MR-proADM and cortisol, and the severity of APE, shedding light on potential applications in postmortem investigations.

Impact of dextrose supplementation on intraoperative blood glucose levels in pediatric patients undergoing major surgeries under general anesthesia with caudal analgesia

Background and Aims

In children undergoing surgery, the stress responses of surgery can result in blood glucose elevation consequent to release of cortisol and catecholamines. The use of a regional block could attenuate the stress responses and lower the blood glucose levels. We compared the blood glucose values at specified time points during surgery with and without additional dextrose to evaluate the need for glucose supplementation as our primary outcome. Intraoperative hemodynamics and the need for any intervention for correction of blood sugars were noted secondarily.

Material and Methods

Children aged between 6 months and 8 years undergoing elective major surgery were randomized to group D (received 1% dextrose in Ringer's lactate) or group P (received only Ringer's lactate). Blood sugars were measured half hourly for 2 h following intubation, and data was analyzed using Student's t-test and Chi-square test.

Results

Demographic variables and the duration of surgery were comparable. The baseline blood glucose value was lower in group D. Analysis of covariates test for a comparison of adjusted mean blood glucose (MBG) showed the values at 30, 60, and 90 min to be comparable. However, toward the end of surgery, the MBG value was significantly higher in group D (P = 0.019). Heart rate and mean arterial pressure were comparable at the same points of measurement.

Conclusion

Dextrose supplementation is not needed for children receiving caudal analgesia for major surgeries of 2-3 h duration and may raise blood sugars at the end of surgery.

The IL-1β/STAT1 Axis inhibits STAT3 function via Sequestration of the transcriptional activator GLIS2, leading to postoperative vascular dysfunction

Surgery-induced endothelial dysfunction is crucial in thrombus formation, driven by the release of inflammatory mediators due to surgical trauma. The STAT family, known for amplifying inflammatory responses via cytokine activation, plays an unclear role in the signaling mechanisms from surgery to molecular activation, and their regulatory effects on inflammation vary. This study aimed to identify key signaling pathways responsible for vascular dysfunction post-surgery and to discover potential targets for predicting or preventing thrombosis. To explore this, endothelial cells were co-cultured with post-surgical trauma serum and analyzed using various assays. Bioinformatics analysis linked surgical trauma with pathways involving thrombosis, interleukins, cytokines, and STAT signaling. Elevated inflammatory mediators were observed in mouse serum post-surgical trauma, with IL-6 activating STAT3 to enhance endothelial proliferation, while IL-1β activated STAT1, inhibiting STAT3's effects. Gli-similar 2 (GLIS2), a novel coactivator of STAT3, was found to regulate STAT transcription. STAT1, however, inhibited GLIS2's interaction with STAT3, suppressing STAT3's role in endothelial proliferation. The study concludes that IL-1β-triggered STAT1 activation impedes GLIS2-STAT3 interaction, reducing STAT3's transcriptional activity and leading to endothelial dysfunction, presenting new targets for preventing post-surgical trauma endothelial dysfunction and thrombosis.

Is it time to Reassess The Role of Preoperative HypoalbuminemiaAmong Geriatric Distal Femur Fracture Patients?

BACKGROUND

Hypoalbuminemia, blanketly defined as Albumin < 3.5 g/dL, is often utilized as a threshold associated with postoperative complications and mortality among orthopedic and non-orthopedic surgical procedures. Albumin level is influenced by a myriad of factors including liver function, malnutrition, and inflammation. This study evaluates the role preoperative albumin as an independent risk factor for mortality and increased length of stay (LOS) among distal femur fracture (DFF) patients.

METHODS

Between 2010 and 2019, the National Surgical Quality Improvement Program (NSQIP) identified isolated closed distal femur fractures preoperative albumin levels using International Classification of Diseases 9th and 10th revisions (ICD9/ICD10) codes [S72.4*; 821.2*]. Albumin was categorized as both continuous and categorical variables: marked hypoalbuminemia (< 2.5 g/dL), mild hypoalbuminemia (2.5-3.5 g/dL), normal albuminemia (3.5-4.5 g/dL) or hyperalbuminemia (> 4.5 g/dL). Primary outcomes included in-hospital mortality and LOS.

RESULTS

The incidence rate of hypoalbuminemia was 54.6% (419/767). Multivariable logistic regression analysis demonstrated that when compared to patients with baseline marked hypoalbuminemia, patients with mild hypoalbuminemia and normal serum albumin reported a respective 82% (OR 0.18, 95% CI [0.04, 0.71], p = 0.014) and 80% (OR: 0.20, 95% CI [0.05, 0.89], p = 0.034) decreased odds of in-hospital mortality. Similarly, a 53.7% (OR 0.46, 95% CI [0.23, 0.94], p = 0.033), 71.1% (OR 0.29, 95% CI [0.14, 0.60], p = 0.001), and 82.8% (OR 0.17, 95% [0.04, 0.75], p = 0.020) decreased odds of exceeding mean LOS was observed among mild hypoalbuminemic, normal, and hyperalbuminemic patients compared to patients with baseline marked hypoalbuminemia.

CONCLUSION

Preoperative hypoalbuminemia is an independent risk factor for increased LOS and mortality among DFFs, controlling for confounding factors. Prospective investigation of albumin risk stratification is warranted to differentiate contributable effects of chronic malnutrition and traumatic inflammatory albumin downregulation among geriatric trauma patients.

LEVEL OF EVIDENCE

Prognostic Level III.

Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy

BACKGROUND

Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival.

METHODS

The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization.

RESULTS

Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]).

CONCLUSIONS

One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Intraoperative Sleep Spindle Activity and Postoperative Sleep Disturbance in Elderly Patients Undergoing Orthopedic Surgery: A Prospective Cohort Study

Purpose

This study aimed to investigate the relationship between intraoperative sleep spindle activity and postoperative sleep disturbance (PSD) in elderly orthopedic surgery patients.

Patients and Methods

In this prospective observational cohort study, we collected intraoperative electroencephalography (EEG) data from 212 elderly patients undergoing orthopedic surgery from May 2023 to December 2023. We used the Athens Insomnia Scale to assess sleep quality on postoperative day (POD) 1 and POD 3 and analyzed the correlation between intraoperative sleep spindle activity and PSD through logistic regression.

Results

The incidence of PSD was 65.6% on POD 1 and 41.9% on POD 3. On the first day, there were no significant differences in intraoperative sleep spindle characteristics between PSD and non-postoperative sleep disturbance (non-PSD) patients. However, by the third day, PSD patients showed lower sigma power compared to non-PSD patients, as well as lower spindle density in the bilateral frontopolar (Fp1/Fp2) and bilateral temporal (F7/F8) channels, with shorter average spindle duration (P < 0.05). Multivariate logistic regression analysis suggested that the average spindle density in F7/F8 channels (OR 0.543, 95% CI 0.375-0.786; P = 0.001) was an independent risk factor for PSD on POD 3. Furthermore, Mini-Mental State Examination (MMSE) could independently predict PSD on POD 1 (OR 0.806, 95% CI 0.656-0.991; P = 0.041) and POD 3 (OR 0.701, 95% CI 0.562-0.875; P = 0.002). Pain on movement and at rest were independently associated with PSD on POD 1 (OR 1.480, 95% CI 1.200-1.824; P < 0.001) and POD 3 (OR 1.848, 95% CI 1.166-2.927; P = 0.009), respectively.

Conclusion

Intraoperative mean spindle density in the F7/F8 channels was an independent risk factor for PSD on POD 3 in elderly patients undergoing orthopedic surgery. MMSE and postoperative pain also independently increased the risk of PSD.

A Multimodal Patient-Centered Teleprehabilitation Approach for Patients Undergoing Surgery for Breast Cancer: A Clinical Perspective

Breast cancer is the most common malignancy among women worldwide, and advances in early detection and treatment have significantly increased survival rates. However, people living beyond breast cancer often suffer from late sequelae, negatively impacting their quality of life. Prehabilitation, focusing on the period prior to surgery, is a unique opportunity to enhance oncology care by preparing patients for the upcoming oncological treatment and rehabilitation. This article provides a clinical perspective on a patient-centered teleprehabilitation program tailored to individuals undergoing primary breast cancer surgery. The proposed multimodal program includes three key components: patient education, stress management, and physical activity promotion. Additionally, motivational interviewing is used to tailor counseling to individual needs. The proposed approach aims to bridge the gap between diagnosis and oncological treatment and provides a holistic preparation for surgery and postoperative rehabilitation in breast cancer patients. The aim of this preparation pertains to improving mental and physical resilience. By integrating current evidence and patient-centered practices, this article highlights the potential for teleprehabilitation to transform clinical care for breast cancer patients, addressing both logistical challenges and holistic well-being.

Early Intravenous Beta-Blockade with Esmolol in Adults with Severe Traumatic Brain Injury: A Phase 2a Intervention Design Study

BACKGROUND

Targeted beta-blockade after severe traumatic brain injury may reduce secondary brain injury by attenuating the sympathoadrenal response. The potential role and optimal dosage for esmolol, a selective, short-acting, titratable beta-1 beta-blocker, as a safe, putative early therapy after major traumatic brain injury has not been assessed.

METHODS

We conducted a single-center, open-label dose-finding study using an adaptive model-based design. Adults (18 years or older) with severe traumatic brain injury and intracranial pressure monitoring received esmolol within 24 h of injury to reduce their heart rate by 15% from baseline of the preceding 4 h while ensuring cerebral perfusion pressure was maintained above 60 mm Hg. In cohorts of three, the starting dosage and dosage increments were escalated according to a prespecified plan in the absence of dose-limiting toxicity. Dose-limiting toxicity was defined as failure to maintain cerebral perfusion pressure, triggering cessation of esmolol infusion. The primary outcome was the maximum tolerated dosage schedule of esmolol, defined as that associated with less than 10% probability of dose-limiting toxicity. Secondary outcomes include 6-month mortality and 6-month extended Glasgow Outcome Scale score.

RESULTS

Sixteen patients (6 [37.5%] female patients; mean age 36 years [standard deviation 13 years]) with a median Glasgow Coma Scale score of 6.5 (interquartile range 5-7) received esmolol. The optimal starting dosage of esmolol was 10 μg/kg/min, with increments every 30 min of 5 μg/kg/min, as it was the highest dosage with less than 10% estimated probability of dose-limiting toxicity (7%). All-cause mortality was 12.5% at 6 months (corresponding to a standardized mortality ratio of 0.63). One dose-limiting toxicity event and no serious adverse hemodynamic effects were seen.

CONCLUSIONS

Esmolol administration, titrated to a heart rate reduction of 15%, is feasible within 24 h of severe traumatic brain injury. The probability of dose-limiting toxicity requiring withdrawal of esmolol when using the optimized schedule is low. Trial registrationI SRCTN, ISRCTN11038397, registered retrospectively January 7, 2021 ( https://www.isrctn.com/ISRCTN11038397 ).

Long-term monocyte activation after coronary artery bypass grafting: An exploratory prospective observational study

Major surgery such as coronary artery bypass grafting (CABG) is associated with an increased post-operative risk of atherosclerotic cardiovascular events. Cells of the innate immune system can adopt a long-lasting pro-inflammatory and atherogenic phenotype after brief exposure to exogenous or endogenous inflammatory stimuli, a process called "trained immunity". We hypothesized that the surgery-induced inflammation leads to sustained alterations in monocyte function, which promote the subsequent occurrence of cardiovascular events. Blood from 13 patients undergoing elective CABG was obtained before, 3-7 days (median 4) after, and 6-8 weeks (median 6) weeks after surgery. At 3-7 days postoperatively, circulating C-reactive protein (CRP) concentration, leukocyte counts and ex vivo Peripheral Blood Mononuclear Cell (PBMC) IL-6, TNFα and IL-1Ra production after stimulation (with various inflammatory stimuli) were significantly increased. Simultaneously, there was a reduction in monocyte HLA-DR expression. 6-8 weeks after CABG there was an ongoing systemic pro-inflammatory state with higher CRP concentrations, increased stimulated ex vivo PBMC IL-6 production, changes in monocytes subsets, and a higher expression of CCR2 on monocytes compared to baseline. In conclusion, CABG induces a persistent systemic inflammatory reaction with a sustained activated monocyte phenotype. This might contribute to the increased atherosclerotic cardiovascular event risk observed in cardiac surgery patients.

A Comparison of Cellular Immune Response and Immunological Biomarkers in Laparoscopic Surgery for Colorectal Cancer and Benign Disorders

BACKGROUND

Surgical trauma causes immune impairment, but it is largely unknown whether surgery for cancer and benign diseases instigate comparable levels of immune inhibition. Here, we compared the impact of laparoscopic surgery on immunological biomarkers in patients with colorectal cancer (CRC) and ventral hernia (VH).

METHODS

Natural Killer cell activity (NKA), leukocyte subsets, and soluble programmed death ligand 1 (sPD-L1) were measured in blood samples collected from CRC (n = 29) and VH (n = 9) patients preoperatively (PREOP) and on postoperative day (POD) 1, 3-6, 2 weeks and 3 months. NKA was evaluated by the NK Vue assay that uses the level of IFNγ as a surrogate marker of NKA. Normal NKA was defined as IFNγ > 250 pg/mL and low NKA was defined as IFNγ < 250 pg/mL.

RESULTS

The CRC cohort was classified into either PREOPLOW having preoperative low NKA or PREOPHIGH having preoperative normal NKA. The median NKA of the PREOPLOW subset was only in the normal range in the POD3 months sample, whereas median NKA of the PREOPHIGH subset and the VH cohort were only low in the POD1 sample. While PREOPLOW differed from VH in the PREOP-, POD1-, and POD3-6 samples (P =.0006, P = .0181, and P = .0021), NKA in PREOPHIGH and VH differed in the POD1 samples (P = .0226). There were no apparent differences in the distribution of leukocyte subsets in the perioperative period between the cohorts.

CONCLUSION

CRC patients with preoperative normal NKA and VH patients showed the same pattern of recovery in NKA, while the CRC subset with preoperative low NKA seemed to experience prolonged NK cell impairment. As low NKA is associated with recurrence, preoperative level of NKA may identify patients who will benefit from immune-enhancing therapy in the perioperative period.

Influence of Nociception Level Monitor (NOL)-Guided Analgesic Delivery on Perioperative Course in Breast Surgeries: A Randomized Controlled Trial

Background and Objectives: Breast cancer surgeries offer challenges in perioperative pain management, especially in the presence of inherent risk of postoperative nausea and vomiting (PONV) and postmastectomy pain syndrome (PMPS). Inappropriate opioid consumption was speculated as one of the reasons. Through this study, the influence of objective pain monitoring through a nociception level monitor (NOL) on perioperative course in breast surgeries was investigated. Materials and Methods: This was a prospective randomized study conducted at a regional hospital. Sixty female patients posted for breast cancer surgery were randomized equally into study and control groups. Both groups were monitored using BIS and NOL, but in the control group, the NOL monitor was blinded by a cover. Both groups received propofol and remifentanil through target-controlled infusions (TCIs) along with interpectoral, pectoserratus (PECS II), and superficial pectointercostal block. The primary outcome was intraoperative opioid consumption. Secondary outcomes were PONV, eligibility for discharge from the recovery room, and symptoms of PMPS after three months. Results: Two patients were excluded. The study group received significantly less remifentanil (0.9 mg in the study group vs. 1.35 mg in the control group, p = 0.033) and morphine (2.5 mg in study group vs. 5 mg in control group, p = 0.013). There was no difference in PMPS symptoms between the groups. The study group showed longer duration of inadequate analgesia (i.e., 7% vs. 10% of the total intraoperative period in control and study group, respectively, p = 0.008). There was no difference in time to eligibility for discharge from the recovery room between the groups. Conclusions: NOL monitor-guided analgesic delivery reduces intraoperative opioid consumption. No difference was demonstrated on PONV, eligibility for discharge from the recovery room, or PMPS symptoms.

Changes in Biomarkers of Inflammation and Oxidative Status in Dogs Subjected to Celiotomy or Video-Assisted Ovariohysterectomy

We evaluated the surgical stress response of dogs undergoing three ovariohysterectomy (OVH) techniques. Twenty-nine healthy females were allocated into groups: celiotomy and ligature (CelioSut), celiotomy and bipolar energy (CelioBip), and a video-assisted technique using two portals and bipolar energy (VidBip). Clinical evaluation was performed, and the following blood analyses were determined: acute phase proteins (C-reactive protein and haptoglobin), white blood cell counting (WBC), and biomarkers of oxidative status. The VidBip required more time despite a smaller incision, lower heart rate, and earlier feeding and urination. All groups had high white blood cells counts; the C-reactive protein (CRP) levels peaked at 6 and 12 h in all groups and was higher in the CelioBip and VidBip groups compared to CelioSut; haptoglobin concentrations peaked at 48 h in all groups and increased in dogs of the CelioSut group. Trolox equivalent antioxidant capacity, ferric reducing ability of plasma, cupric reducing antioxidant capacity, and advanced oxidation protein were not significantly different among the groups or time points. Total thiol concentrations were lower in CelioBip and CelioSut groups. All surgical techniques induced an inflammatory and oxidative stress response, but the video-assisted technique produced early clinical recovery. The bipolar device produces fewer disturbances than suspensory ligament rupture and ligature.

Effect of Remimazolam- Vs Propofol-Based Intravenous Anesthesia on Surgical Stress Response and Post-Operative Immune Function in Patients with Gastric Radical Surgery

PURPOSE

This study aimed to compare the impact of remimazolam-based versus propofol-based intravenous anesthesia on surgical stress and post-operative immune function in patients undergoing gastric radical surgery.

PATIENTS AND METHODS

Sixty-eight patients aged 50 to 80 undergoing gastric radical surgery were randomly assigned to the remimazolam group (group R) or the propofol group (group P), receiving remimazolam or propofol-based intravenous anesthesia, respectively. The primary outcome measured was peri-operative serum stress indicators and lymphocyte subtypes. Secondary outcomes included hemodynamic vitals, recovery quality, postoperative pain profiles and potential adverse effects.

RESULTS

The demographic and surgical characteristics of the 60 analyzed patients were comparable. The absolute counts of CD3+CD4+ and CD3+CD8+ cell decreased significantly on POD1 compared with baseline. On POD3, the numbers of CD3+CD4+ cells in group R were lower than baseline and Group P, whereas the CD3+CD8+ cell counts in both groups were lower than baseline, with group R higher than group P. The CD3-CD16+CD56+ cell numbers in both groups on POD1 and POD3 decreased significantly compared to baseline with group P lower than group R on POD3. The serum levels of IL-1β, IL-6, TNF-α, ACTH and COR rose sharply 2 hours after the beginning of surgery compared to baseline. Notably, all these parameters in group R were higher than those in group P. Additionally, blood pressure and intra-operative vasoactive drug frequency in group R were higher than that in group P. No significant differences in recovery quality, postoperative pain profiles, and potential adverse effects were observed.

CONCLUSION

Remimazolam-based intravenous anesthesia might favour the recovery of cellular immune function in early postoperative period compared to propofol. On the contrary, remimazolam was inferior to propofol in suppressing surgical stress. Further studies with larger sample sizes are needed to confirm our findings.

Hypothalamic corticotropin-releasing hormone neurons modulate sevoflurane anesthesia and the post-anesthesia stress responses

General anesthesia (GA) is an indispensable procedure necessary for safely and compassionately administering a significant number of surgical procedures and invasive diagnostic tests. However, the undesired stress response associated with GA causes delayed recovery and even increased morbidity in the clinic. Here, a core hypothalamic ensemble, corticotropin-releasing hormone neurons in the paraventricular nucleus of the hypothalamus (PVHCRH neurons), is discovered to play a role in regulating sevoflurane GA. Chemogenetic activation of these neurons delay the induction of and accelerated emergence from sevoflurane GA, whereas chemogenetic inhibition of PVHCRH neurons accelerates induction and delays awakening. Moreover, optogenetic stimulation of PVHCRH neurons induce rapid cortical activation during both the steady and deep sevoflurane GA state with burst-suppression oscillations. Interestingly, chemogenetic inhibition of PVHCRH neurons relieve the sevoflurane GA-elicited stress response (e.g., excessive self-grooming and elevated corticosterone level). These findings identify PVHCRH neurons modulate states of anesthesia in sevoflurane GA, being a part of anesthesia regulatory network of sevoflurane.

Enhanced Recovery After Surgery (ERAS) Practices in Minimally Invasive Gynaecologic Surgery: A National Survey

OBJECTIVES

Enhanced recovery after surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, reducing postoperative complications and recovery time. This study assessed the Canadian application of, and adherence to, ERAS recommendations during minimally invasive gynaecologic surgery, and identified barriers to ERAS uptake.

METHODS

A self-administered cross-sectional survey was distributed to obstetrics and gynaecology residents, fellows, and attendings through 3 national listservs from February 2021 to January 2022. The survey assessed 14 perioperative components per the American Association of Gynecologic Laparoscopists ERAS consensus guidelines. Two study groups were defined-participants with versus without an established ERAS program-and comparison analyses as well as inferential statistical tests were performed.

RESULTS

Overall, 158 responses were analyzed. A total of 41.9% of respondents work in a centre with an ERAS program. Adherence to ERAS recommendations was high with engaging patients in the operative processes, changing equipment after a contaminated procedure, discontinuing urinary catheters, and initiating early postoperative mobilization. ERAS programming enhanced adherence to preoperative carbohydrate loading, intraoperative fluid management, normothermia, and bowel-regimen adjuncts (P < 0.05). Despite ERAS programming, adherence to some recommendations-preoperative fasting, and comorbidity optimization-remained low. Most respondents felt that ERAS is safe (98%) and improves outcomes (82%).

CONCLUSIONS

While the implementation of formal ERAS pathways differs between provinces and hospitals, practitioners across Canada engage in various ERAS components. ERAS program sites had higher adherence to some perioperative recommendations; however, some high-level evidence recommendations still have national adherence gaps. Targeted research around low-adherence components would help identify and address barriers to optimizing surgical care.

Effect of Ketamine on the Bispectral Index, Spectral Edge Frequency, and Surgical Pleth Index During Propofol-Remifentanil Anesthesia: An Observational Prospective Trial

BACKGROUND

Ketamine administration during stable propofol anesthesia is known to be associated with an increase in bispectral index (BIS) but a "deepening" in the level of hypnosis. This study aimed to evaluate the association between the effect-site concentration of ketamine (CeK) and 2 electroencephalogram (EEG)-derived parameters, the BIS and spectral edge frequency (SEF95), after the administration of a ketamine bolus. Secondary aims included investigating the BIS and SEF95 variations with time and changes in the surgical pleth index (SPI).

METHODS

We conducted an observational, prospective, single-center study analyzing intraoperative data from 14 adult female patients undergoing breast oncologic surgery. During stable propofol-remifentanil target-controlled infusion (TCI) anesthesia, a ketamine analgesic bolus was delivered with the target CeK set to 1 μg.mL-1 (Domino model) corresponding to a dose of 0.57 mg.kg-1 (interquartile range [IQR] 0.56-0.57 mg.kg-1). Once the CeK reached a value of 1 μg.mL-1, the target CeK was set to 0 μg.mL-1. We determined the median BIS, SEF95, and SPI trends with time and as a function of the modeled CeK.

RESULTS

BIS and SEF95 showed no significant change from when ketamine was administered to when CeK=1 μg.mL-1, but a significant increase was observed at lower CeKs. The maximum BIS was reached at 16.0 minutes [10.2-22.7 minutes] after CeK=1 μg.mL-1, at CeK=0.22 μg.mL-1 [0.12-0.41 μg.mL-1]. The peak SEF95 value was observed at 10.0 minutes [8.62-14.1 minutes] after CeK=1 μg.mL-1, at CeK=0.43 μg.mL-1 [0.25-0.50 μg.mL-1]. No significant association was found between CeK and the registered SPI values.

CONCLUSIONS

Our results show that BIS and SEF95, but not SPI, follow a CeK-dependent trend after administering a ketamine bolus. Interestingly, their peak values were not reached at CeK=1 μg.mL-1, but after several minutes after the drug infusion at CeKs in the 0.2 to 0.5 μg.mL-1 range. This may be explained by the specific pharmacodynamics of ketamine and its varying effects at different concentrations, as well as by the time delay associated with the calculation of the BIS.

Fluid Management in Critically Ill Children: Single-Center Retrospective Comparison of Trauma and Postoperative Patients, 2020-2022

OBJECTIVE

Injury and surgery both represent well-defined starting points of a predictable inflammatory response, but the consequent response to IV fluids has not been studied. We aimed to review and compare our single-center fluid management strategies in these two populations.

DESIGN

Retrospective cohort study from January 2020 to July 2022. The primary outcome was total IV fluid volume administered. Net fluid balances and select clinical outcomes were also evaluated.

SETTING

Single tertiary academic center and level 1 pediatric trauma center in New York.

PATIENTS

A dataset of critically ill trauma and surgical patients aged 0-18 years who were admitted to the PICU, 2020-2022. Trauma patients had at least moderate traumatic injuries (Injury Severity Score ≥ 9) and surgical patients had at least a 1-hour operation time.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 25 trauma and 115 surgical patients. During the first 5 days of hospitalization, we did not identify an association between grouping and total IV fluids administered and fluid balance in the prehospital, emergency department, and operating room ( p = 0.90 and p = 0.79), even when adjusted for weight ( p = 0.96). Time trend graphs of net fluid balance and IV fluid administered illustrated analogous fluid requirement and response with the transition from net positive to net negative fluid balance between 48 and 72 hours. There was an association between total IV fluid and ventilator requirement ( p = 0.003).

CONCLUSIONS

Critically ill pediatric trauma and postoperative patients seem to have similar fluid management and balance after injury or surgery. In our opinion, these two critically ill populations could be combined in large prospective studies on optimal fluid therapy in critically ill children.

Comparison of tissue damage and inflammation for robotic laparoscopy and conventional laparoscopy in early endometrial cancer

Introduction

This study was to analyze the dynamics of tissue damage and inflammatory response markers perioperatively and whether these differ between robotic laparoscopy and conventional laparoscopy in early endometrial cancer.

Methods

In a randomized controlled trial conducted at SHANGHAI FIRST MATERNITY and INFANT HOSPITAL, eighty women with early-stage, low-risk endometrial cancer were randomly assigned to receive either robotic or conventional laparoscopy. Blood samples were collected at admission, immediately before surgery, 2 h after surgery, 24 h after surgery, 48 h after surgery, and 1 week after surgery. The samples were analyzed for various biomarkers associated with inflammatory processes and tissue damage. These included high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBC), platelet count, interleukin-6 (IL-6), cortisol, creatine kinase (CK), and tumor necrosis factor-alpha (TNF-α). These markers provide insights into the underlying physiological responses and potential tissue-level changes within the study participants.

Results

There was no significant difference in clinical and preoperative data between two groups. The results showed that the patients who underwent robotic laparoscopy had a longer pre-surgical time compared to the conventional laparoscopy group. However, the robotic group had shorter operating times, quicker vaginal cuff closures, and lower estimated blood loss compared to the conventional laparoscopy group. The hospital stays, Visual Analog Scale (VAS) score and drainage volume on the first day after operation were lower in robotic group compared to conventional laparoscopy group. hs-CRP, WBC, IL-6 and cortisol were significantly lower in the robotic group, though the differences were transient.

Discussion

This study demonstrated that robotic laparoscopy, used in early endometrial cancer treatment, leads to a reduced inflammatory response, less tissue damage, and lower stress levels, as evidenced by decreased levels of hs-CRP, IL-6, and cortisol, compared to conventional laparoscopy. These findings suggest that robot- laparoscopy may facilitate a quicker recovery and improve patient-reported outcomes.

Modelling hemodynamics regulation in rats and dogs to facilitate drugs safety risk assessment

Pharmaceutical companies routinely screen compounds for hemodynamics related safety risk. In vitro secondary pharmacology is initially used to prioritize compounds while in vivo studies are later used to quantify and translate risk to humans. This strategy has shown limitations but could be improved via the incorporation of molecular findings in the animal-based toxicological risk assessment. The aim of this study is to develop a mathematical model for rat and dog species that can integrate secondary pharmacology modulation and therefore facilitate the overall pre-clinical safety translation assessment. Following an extensive literature review, we built two separate models recapitulating known regulation processes in dogs and rats. We describe the resulting models and show that they can reproduce a variety of interventions in both species. We also show that the models can incorporate the mechanisms of action of a pre-defined list of 50 pharmacological mechanisms whose modulation predict results consistent with known pharmacology. In conclusion, a mechanistic model of hemodynamics regulations in rat and dog species has been developed to support mechanism-based safety translation in drug discovery and development.

In Vivo Evaluation of Demineralized Bone Matrix with Cancellous Bone Putty Formed Using Hydroxyethyl Cellulose as an Allograft Material in a Canine Tibial Defect Model

Demineralized bone matrix (DBM) is a widely used allograft material for bone repair, but its handling properties and retention at defect sites can be challenging. Hydroxyethyl cellulose (HEC) has shown promise as a biocompatible carrier for bone graft materials. This study aimed to evaluate the efficacy of DBM combined with cancellous bone putty formed using HEC as an allograft material for bone regeneration in a canine tibial defect model. Experiments were conducted using dogs with proximal tibial defects. Four groups were compared: empty (control group), DBM + HEC (DH), DBM + cancellous bone + HEC (DCH), and DBM + cancellous bone + calcium phosphate + HEC (DCCH). Radiographic, micro-computed tomography (CT), and histomorphometric evaluations were performed 4 and 8 weeks postoperatively to assess bone regeneration. The Empty group consistently exhibited the lowest levels of bone regeneration throughout the study period, indicating that DBM and cancellous bone with HEC significantly enhanced bone regeneration. At week 4, the DCCH group showed the fastest bone regeneration on radiography and micro-computed tomography. By week 8, the DCH group showed the highest area ratio of new bone among all experimental areas, followed by the DH and DCCH groups. This study demonstrated that HEC significantly enhances the handling, mechanical properties, and osteogenic potential of DBM and cancellous bone grafts, making it a promising carrier for clinical applications in canine allograft models. When mixed with allograft cancellous bone, which has high porosity and mechanical strength, it becomes a promising material offering a more effective and reliable option for bone repair and regeneration.