Effect of an intravenous acetaminophen/ibuprofen fixed-dose combination on postoperative opioid consumption and pain after video-assisted thoracic surgery: a double-blind randomized controlled trial

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) often induces significant postoperative pain, potentially leading to chronic pain and decreased quality of life. This study aimed to evaluate the acetaminophen/ibuprofen combination effectiveness in reducing analgesic requirements and pain intensity in patients undergoing VATS.

STUDY DESIGN

This is a double-blinded randomized controlled trial.

METHODS

Adult patients scheduled for elective VATS for lung resection were randomized to receive either intravenous acetaminophen and ibuprofen (intervention group) or 100 mL normal saline (control group). Treatments were administered post-anesthesia induction and every 6 h for three cycles. The primary outcome was total analgesic consumption at 24 h postoperatively. Secondary outcomes were cumulative analgesic consumption at 2 and 48 h; analgesic-related side effects at 2, 24, and 48 h; quality of recovery at 24 h and 48 h postoperatively; pain intensity at rest and during coughing; and rescue analgesics use. Chronic postsurgical pain (CPSP) was assessed through telephone interviews 3 months postoperatively.

RESULTS

The study included 96 participants. The intervention group showed significantly lower analgesic consumption at 24 h and 48 h postoperatively (24 h: median difference: - 100 µg equivalent intravenous fentanyl [95% confidence interval (CI) - 200 to - 5 μg], P = 0.037; 48 h: median difference: - 140 μg [95% CI - 320 to - 20 μg], P = 0.035). Compared to the controls, the intervention group exhibited a significantly lower quality of recovery 24 h post-surgery, with no significant difference at 48 h. All pain scores except for coughing at 48 h post-surgery were significantly lower in the intervention group compared to the controls. No significant differences were observed between the groups in postoperative nausea and vomiting occurrence, hospital stay length, and CPSP.

CONCLUSION

Perioperative administration of acetaminophen/ibuprofen significantly decreased analgesic needs in patients undergoing VATS, providing an effective postoperative pain management strategy, and potentially minimizing the need for stronger analgesics.

Intraoperative Normal Saline Administration and Acute Kidney Injury in Patients Undergoing Liver Transplantation

BACKGROUND

Normal saline is still used in patients undergoing living donor liver transplantation (LDLT) with normonatremia. We investigated whether the normal saline administered during LDLT is associated with the increased risk of acute kidney injury (AKI) compared with the balanced crystalloids.

METHODS

We reviewed 1011 cases undergoing LDLT. The primary exposure variable was normal saline administered intraoperatively compared with the balanced crystalloid. To compare the risk of AKI after adjusting for potential confounders of baseline characteristics and surgical parameters, a propensity score matching analysis was performed. As a sensitivity analysis, ordinal logistic regression analysis was performed for AKI using inverse probability of treatment weighting (IPTW).

RESULTS

The incidence of AKI was significantly higher in the saline group (n = 88/174, 50.6%) than in the balanced group (n = 67/174, 38.5%) after matching (P = .010). The incidence of stage 2 or 3 AKI was also significantly higher in the saline group (n = 26/174, 14.9%) than in the balanced group (n = 43/174, 24.7%) after matching (P = .022). The length of hospital stay was significantly longer in the saline group than in the balanced group after matching. Ordinal logistic regression analysis using IPTW showed that the saline group showed a significant association of saline administration with the risk of AKI (odds ratio 1.23, 95% CI 1.05-1.28, P = .013).

CONCLUSION

Our propensity score analysis using propensity score matching and IPTW showed that normal saline administration during LDLT is associated with a high risk of postoperative AKI and longer hospital stays. However, our results should be interpreted carefully due to the relatively long period of data collection.

The impact of preoperative coronavirus disease 19 infection on early postoperative mortality during the vaccination era: a nationwide retrospective cohort study

BACKGROUND

We aimed to investigate the optimal surgical timing in patients with preoperative coronavirus disease 2019 (COVID-19) infection to minimize postoperative morbidity and mortality during the COVID-19 vaccination era.

METHODS

The Korean nationwide data on patients who underwent standard surgery under general anesthesia in 2021 were analyzed. Patients were categorized based on the time from COVID-19 diagnosis to surgery: 0-4, 5-8, > 8 weeks, and those without preoperative COVID-19 infection. Multivariable logistic regression analysis, considering preoperative COVID-19 vaccination status (fully vaccinated vs. unvaccinated or partially vaccinated), was performed to associate the preoperative COVID-19 infection timing with 30- and 90-day postoperative mortality and 30-day respiratory complications.

RESULTS

Among the 750,175 included patients, 28.2% were preoperatively fully vaccinated. Compared with patients without prior COVID-19 infection, those who had surgery 0-4 weeks (adjusted odds ratio [OR]: 4.28, 95% CI [1.81, 10.13], P = 0.001) and 5-8 weeks (adjusted OR: 3.38, 95% CI [1.54, 7.44], P = 0.002) after COVID-19 infection had a significantly increased risk of 30-day mortality. Preoperative full vaccination was significantly associated with a decrease in 90-day mortality (adjusted OR: 0.93, 95% CI [0.89, 0.98], P = 0.007) and 30-day respiratory complications (adjusted OR: 0.85, 95% CI [0.82, 0.87], P < 0.001), but not with 30-day mortality (P = 0.916).

CONCLUSIONS

COVID-19 infection eight weeks preoperatively was associated with an increased 30-day postoperative mortality. Preoperative full vaccination was not associated with 30-day mortality but was related to lower risk of 90-day mortality and 30-day respiratory complications.

Association between waist circumference change after smoking cessation and incidence of hypertension in Korean adults

OBJECTIVES

This study investigates the association between smoking cessation and hypertension incidence, as well as the association between waist circumference change after smoking cessation and hypertension incidence.

STUDY DESIGN

This was a nationwide population-based cohort study.

METHODS

We used the Korean Health Screening Cohort data and included 158,505 participants who had undergone two or more health examinations between 2008 and 2011, with follow-ups throughout 2019. Smoking cessation and waist changes were captured based on difference between first and follow-up screening dates. Hazard ratio (HR) and 95% confidence interval (CI) for hypertension risk were estimated using multivariable Cox proportional hazard regression models.

RESULTS

There were 31,270 cases of hypertension during a median follow-up of 8.50 years. After adjusting for potential confounding factors, HR for hypertension were 1.01 (95% CI: 0.97-1.05), 0.91 (95% CI: 0.87-0.95), and 0.88 (95% CI: 0.85-0.91) for recent quitters, long-term quitters, and non-smokers, respectively, compared with current smokers. HR for hypertension, compared with current smokers, were 0.89 (95% CI: 0.84-0.94), 0.91 (95% CI: 0.85-0.97), and 0.99 (95% CI: 0.91-1.08) for long-term quitters with no waist gain, long-term quitters with waist gain of 0.1-5.0 cm, and long-term quitters with waist gain of ≥5.0 cm, respectively.

CONCLUSIONS

Long-term smoking cessation was significantly associated with decreased risk of hypertension, and long-term smoking cessation with no waist gain or less than 5.0 cm of waist gain was significantly associated with decreased risk of hypertension. However, more than 5.0 cm of waist gain can attenuate the effect of long-term smoking cessation on lowering the risk of hypertension.

Influence of Aza-Glycine Substitution on the Internalization of Penetratin

The cell-penetrating peptide (CPP) penetratin has gained much attention over many years due to its potential role as a transporter for a broad range of cargo into cells. The modification of penetratin has been extensively investigated too. Aza-peptides are peptide analogs in which one or more of the amino residues are replaced by a semicarbazide. This substitution results in conformational restrictions and modifications in hydrogen bonding properties, which affect the structure and may lead to enhanced activity and selectivity of the modified peptide. In this work, the Trp residues of penetratin were substituted by aza-glycine or glycine residues to examine the effect of these modifications on the cellular uptake and the internalization mechanism. The substitution of Trp48 or Trp48,56 dramatically reduced the internalization, showing the importance of Trp48 in cellular uptake. Interestingly, while aza-glycine in the position of Trp56 increased the cellular uptake, Gly reduced it. The two Trp-modified derivatives showed altered internalization pathways, too. Based on our knowledge, this is the first study about the effect of aza-amino acid substitution on the cell entry of CPPs. Our results suggest that aza-amino acid insertion is a useful modification to change the internalization of a CPP.

Efficacy of high-voltage, long-duration pulsed radiofrequency for the treatment of acute herpes zoster-related trigeminal neuralgia in a patient with permanent pacemaker

Background

Recognizing the seriousness of the misuse and abuse of medical narcotics, the South Korean government introduced the world's first narcotic management system, the Narcotics Information Management System (NIMS). This study aimed to explore the recent one-year opioid prescribing patterns in South Korea using the NIMS database.

Methods

This study analyzed opioid prescription records in South Korea for the year 2022, utilizing the dispensing/administration dataset provided by NIMS. Public data from the Korean Statistical Information Service were also utilized to explore prescription trends over the past four years. The examination covered 16 different opioid analgesics, assessed by the total number of units prescribed based on routes of administration, type of institutions, and patients’ sex and age group. Additionally, the disposal rate for each ingredient was computed.

Results

In total, 206,941 records of 87,792,968 opioid analgesic units were analyzed. Recently, the overall quantity of prescribed opioid analgesic units has remained relatively stable. The most prescribed ingredient was oral oxycodone, followed by tapentadol and sublingual fentanyl. Tertiary hospitals had the highest number of dispensed units (49.4%), followed by community pharmacies (40.2%). The highest number of prescribed units was attributed to male patients in their 60s. The disposal rates of the oral and transdermal formulations were less than 0.1%.

Conclusions

Opioid prescription in South Korea features a high proportion of oral formulations, tertiary hospital administration, pharmacy dispensing, and elderly patients. Sustained education and surveillance of patients and healthcare providers is required.

Dual-channel fluorescent probe for discriminative detection of H2S and N2H4: Exploring sensing mechanism and real-time applications

A highly efficient system incorporates the real-time visualization of the two toxic molecules (H2S and N2H4) and the recognition of corresponding transforms using a fluorescent sensor. In this paper, a dual-responsive probe (QS-DNP) based on methylquinolinium-salicyaldehyde-2,4-dinitrophenyl was developed that can simultaneously detect H2S and N2H4 at two independent fluorescent channels without signal crosstalk. QS-DNP showed excellent anti-interference, high selectivity, outstanding water solubility, low LOD values (H2S: 51 nM; N2H4: 40 nM), low cytotoxicity, and mitochondrial localization properties. The 2,4-dinitrophenyl site was sensitive to H2S, and the CC bridge was reactive to N2H4, with strong fluorescence at 680 and 488 nm, respectively. The wavelength gap between these two channels is 192 nm; verify that there is no signal crosstalk throughout detection. By this means, the probe was used to simultaneously detect H2S and N2H4 in real soil samples, food samples, and living cells. The endogenous H2S and N2H4 were monitored in HeLa cells and investigated the mitochondria organelle of living cells with a positive charge on QS-DNP. Overall, all results emphasize that the QS-DNP probe is a powerful tool for the simultaneous detection of H2S and N2H4 and presents a potential new sensing approach.

Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy

BACKGROUND

General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery.

METHODS

In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared.

RESULTS

Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively.

CONCLUSIONS

Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

Quinoline-derived electron-donating/withdrawing fluorophores for hydrazine detection and applications in environment and bioimaging

Substitution can be employed to competently tune the photophysical properties of chemosensors. The effect of substituents on the absorption and emission properties of quinoline probes was investigated. Therefore, salicylaldehyde (S), N-diethylamino-salicylaldehyde (D), and nitro-salicylaldehyde (W)-based quinoline Schiff base derivatives were investigated with hydrazine and studied for their photophysical properties. The nucleophilic substitution reaction was used as a sensing mechanism between the probes and hydrazine and investigated with 1H NMR, HR-MS characterizations, and DFT calculations. The sensitivity of QW-R is greater than that of QS-R and QD-R because of the stronger intramolecular charge transfer (ICT) in QW-R. The calculated LOD values are 28 nM for QS-R, 30 nM for QD-R, and 9 nM for QW-R. The probes were employed to monitor gaseous hydrazine using a smartphone and analyze solution forms of hydrazine in soil, water, and food samples, and living cells. Moreover, the in situ hydrazine release was monitored with bioimaging by administering an isoniazid drug. Significantly, the electronic effect of substituents over fluorescence showing, ranging from electron-donating to electron-withdrawing was investigated. We anticipate that this approach may be a promising strategy for the rational design of fluorescent sensors.

Challenging issues of implementing enhanced recovery after surgery programs in South Korea

This review discusses the challenges of implementing enhanced recovery after surgery (ERAS) programs in South Korea. ERAS is a patient-centered perioperative care approach that aims to improve postoperative recovery by minimizing surgical stress and complications. While ERAS has demonstrated significant benefits, its successful implementation faces various barriers such as a lack of manpower and policy support, poor communication and collaboration among perioperative members, resistance to shifting away from outdated practices, and patient-specific risk factors. This review emphasizes the importance of understanding these factors to tailor effective strategies for successful ERAS implementation in South Korea's unique healthcare setting. In this review, we aim to shed light on the current status of ERAS in South Korea and identify key barriers. We hope to encourage Korean anesthesiologists to take a leading role in adopting the ERAS program as the standard for perioperative care. Ultimately, our goal is to improve the surgical outcomes of patients using this proactive approach.

Pulmonary artery catheter monitoring versus arterial waveform-based monitoring during liver transplantation: a retrospective cohort study

Although pulmonary artery catheter (PAC) has been used during liver transplantation surgery, the usefulness of PAC has rarely been investigated. We evaluated whether the use of PAC is associated with better clinical outcomes compared to arterial waveform-based monitoring after liver transplantation. A total of 1565 cases undergoing liver transplantation were reviewed. We determined whether patients received PAC or not and divided our cohort into the PAC with hemodynamic monitoring using PAC and the non-PAC with arterial waveform-based monitoring using FloTrac-Vigileo. Propensity score matching was performed. Acute kidney injury (AKI), early allograft dysfunction (EAD) and 1-year all-cause mortality or graft failure were compared in the matched cohorts. Logistic regression analysis was performed in the inverse probability of treatment-weighted (IPTW) cohort for postoperative EAD and AKI, respectively. Five-year overall survival was compared between the two groups. In the matched cohort, there was no significant difference in the incidence of AKI, EAD, length of hospital or ICU stay, and 1-year all-cause mortality between the groups. In the IPTW cohort, the use of PAC was not a significant predictor for AKI or EAD (AKI: odds ratio (95% confidence interval) of 1.20 (0.47-1.56), p = 0.229; EAD: 0.99 (0.38-1.14), p = 0.323). There was no significant difference in the survival between groups after propensity score matching (Log-rank test p = 0.578). In conclusion, posttransplant clinical outcomes were not significantly different between the groups with and without PAC. Anesthetic management without the use of PAC may be possible in low-risk patients during liver transplantation. The risk should be carefully assessed by considering MELD scores, ischemic time, surgical history, previous treatment of underlying liver disease, and degree of portal and pulmonary hypertension.Registration: https://clinicaltrials.gov/ct2/show/NCT05457114 (registration date: July 15, 2022).

Comparison of invasive and non-invasive measurements of cardiac index and systemic vascular resistance in living-donor liver transplantation: a prospective, observational study

BACKGROUND

Based on the controversy surrounding pulmonary artery catheterization (PAC) in surgical patients, we investigated the interchangeability of cardiac index (CI) and systemic vascular resistance (SVR) measurements between ClearSight™ and PAC during living-donor liver transplantation (LDLT).

METHODS

This prospective study included consecutively selected LDLT patients. ClearSight™-based CI and SVR measurements were compared with those from PAC at seven LDLT-stage time points. ClearSight™-based systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressures were also compared with those from femoral arterial catheterization (FAC). For the comparison and analysis of ClearSight™ and the reference method, Bland-Altman analysis was used to analyze accuracy while polar and four-quadrant plots were used to analyze the trending ability.

RESULTS

From 27 patients, 189 pairs of ClearSight™ and reference values were analyzed. The CI and SVR performance errors (PEs) exhibited poor accuracy between the two methods (51.52 and 51.73%, respectively) in the Bland-Altman analysis. CI and SVR also exhibited unacceptable trending abilities in both the polar and four-quadrant plot analyses. SAP, MAP, and DAP PEs between the two methods displayed favorable accuracy (24.28, 21.18, and 26.26%, respectively). SAP and MAP exhibited acceptable trending ability in the four-quadrant plot between the two methods, but not in the polar plot analyses.

CONCLUSIONS

During LDLT, CI and SVR demonstrated poor interchangeability, while SAP and MAP exhibited acceptable interchangeability between ClearSight™ and FAC.

Postoperative NSAIDs use and the risk of anastomotic leakage after restorative resection for colorectal cancer

BACKGROUND

Although non-steroidal anti-inflammatory drugs (NSAIDs) are useful options for multimodal opioid-sparing analgesia, their effect on anastomotic leakage (AL) after colorectal surgery remains unclear. We aimed to investigate the association between early postoperative NSAID use and AL occurrence in patients who underwent colorectal cancer surgery at a high-volume tertiary care center.

METHODS

This retrospective observational study included all adult patients who underwent elective colorectal cancer resection surgery during 2011-2021 at a tertiary teaching hospital. Based on NSAID use within five postoperative days, patients were classified into either NSAID or no NSAID groups. We performed multivariable logistic regression analysis for the primary outcome, AL, within the first 30 postoperative days, before and after propensity score analysis using stabilized inverse probability of treatment weighting (sIPTW).

RESULTS

Among the 7928 patients analyzed, 0.6% experienced AL after surgery. The occurrence rates of AL were 1.7% (12/714) and 0.5% (37/7214) in the NSAID and no NSAID groups, respectively. Multivariable logistic regression analysis revealed that early postoperative NSAID use was significantly associated with AL [odds ratio (OR), 3.41; 95% confidence interval (CI), 1.76-6.60; P < 0.001]. Significance was maintained after sIPTW (OR, 3.65; 95% CI, 1.86-6.72; P < 0.001).

CONCLUSION

Early postoperative NSAID use was significantly associated with AL in patients undergoing colorectal cancer surgery at a high-volume tertiary care center. Further prospective studies are required to investigate NSAIDs' clinically meaningful unfavorable effects following colorectal cancer surgery.

Correlation Between Pain Intensity and Quality of Recovery After Video-Assisted Thoracic Surgery for Lung Cancer Resection

Purpose

The Quality of Recovery-15 (QoR-15) questionnaire provides a multifaceted assessment of postoperative recovery, and the resulting score is recommended as an endpoint in clinical studies focused on postoperative pain. We aimed to investigate the correlation between the QoR-15 score and postoperative pain intensity in surgical patients.

Patients and Methods

Adult patients who underwent video-assisted thoracoscopic surgery (VATS) for lung cancer resection and were enrolled in a prospective registry or in a previous prospective study were included in this study. Baseline and perioperative data, including the results of assessment using the Korean version of the QoR-15 (QoR-15K) questionnaire at 48 hours postoperatively, were collected from the database. Correlations between the QoR-15K total score, questionnaire dimensions, and postoperative pain intensity at 48 hours postoperatively were determined using the Spearman correlation coefficient (ρ).

Results

We analyzed a total of 137 eligible patients. Significant negative correlations were noted between the QoR-15K total score and pain intensity at rest (ρ = -0.45, 95% confidence interval [CI]: -0.57 - -0.31, P < 0.001) and during coughing (ρ = -0.55, 95% CI: -0.65 - -0.42, P < 0.001) at 48 hours postoperatively. The pain dimension and pain intensity at 48 hours postoperatively showed significant correlations with physical comfort, emotional state, and physical independence dimensions. Multivariable logistic regression revealed a significant negative association between the pain score at 24 hours postoperatively and good or excellent postoperative recovery.

Conclusion

The results support the impact of postoperative pain on the overall postoperative quality of recovery in patients who underwent VATS for lung cancer resection. Moreover, the QoR-15K score may be considered as a primary endpoint in clinical studies on postoperative pain control.

The effect of high perioperative inspiratory oxygen fraction for abdominal surgery on surgical site infection: a systematic review and meta-analysis

Guidelines from the World Health Organization strongly recommend the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anesthesia to reduce surgical site infection (SSI). However, previous meta-analyses reported inconsistent results. We aimed to address this controversy by focusing specifically on abdominal surgery with relatively high risk of SSI. Medline, EMBASE, and Cochrane CENTRAL databases were searched. Randomized trials of abdominal surgery comparing high to low perioperative FiO2 were included, given that the incidence of SSI was reported as an outcome. Meta-analyses of risk ratios (RR) were performed using a fixed effects model. Subgroup analysis and meta-regression were employed to explore sources of heterogeneity. We included 27 trials involving 15977 patients. The use of high FiO2 significantly reduced the incidence of SSI (n = 27, risk ratio (RR): 0.87; 95% confidence interval (CI): 0.79, 0.95; I2 = 49%, Z = 3.05). Trial sequential analysis (TSA) revealed that z-curve crossed the trial sequential boundary and data are sufficient. This finding held true for the subgroup of emergency operations (n = 2, RR: 0.54; 95% CI: 0.35, 0.84; I2 = 0%, Z = 2.75), procedures using air as carrier gas (n = 9, RR: 0.79; 95% CI: 0.69, 0.91; I2 = 60%, Z = 3.26), and when a high level of FiO2 was maintained for a postoperative 6 h or more (n = 9, RR: 0.68; 95% CI: 0.56, 0.83; I2 = 46%, Z = 3.83). Meta-regression revealed no significant interaction between SSI with any covariates including age, sex, body-mass index, diabetes mellitus, duration of surgery, and smoking. Quality of evidence was assessed to be moderate to very low. Our pooled analysis revealed that the application of high FiO2 reduced the incidence of SSI after abdominal operations. Although TSA demonstrated sufficient data and cumulative analysis crossed the TSA boundary, our results should be interpreted cautiously given the low quality of evidence.Registration: https://www.crd.york.ac.uk/prospero (CRD42022369212) on October 2022.

The verification of delta SCF and Slater's transition state theory for the calculation of core ionization energy

The core ionization energies of second- and third-period elements of the molecules C2 H5 NO2 , SiF4 , Si(CH3 )4 , PF3 , POF3 , PSF3 , CS2 , OCS, SO2 , SO2 F2 , CH3 Cl, CFCl3 , SF5 Cl, and Cl3 PS are calculated by using Hartree-Fock (HF), and Kohn-Sham (KS) with BH&HLYP, B3LYP, and LC-BOP functionals. We used ΔSCF, Slater's transition state (STS), and two previously proposed shifted STS (1) and shifted STS (2) methods, which have been developed. The errors of ΔSCF and STS come mainly from the self-interaction errors (SIE) and can be corrected with a shifting scheme. In this study, we used the shifting parameters determined for each atom. The shifted STS (1) reproduces ΔSCF almost perfectly with mean absolute deviations (MAD) of 0.02 eV. While ΔSCF and STS vary significantly depending on the functional used, the variation of shifted STS (2) is small, and all shifted STS (2) values are close to the observed ones. The deviations of the shifted STS (2) from the experiment are 0.24 eV (BH&HLYP), 0.19 eV (B3LYP), and 0.23 eV (LC-BOP). These results further support the use of shifted STS methods for predicting the core ionization energies.

Trans-anal small bowel evisceration in a patient with a perforated rectal prolapse

SUMMARY

An 85-year-old lady with a history of chronic constipation presented with gangrenous small bowel protruding from the anus through a hole in a prolapsed rectum. At surgery, a resection of 125 cm of gangrenous small bowel was performed in the perineum prior to laparotomy, where rectal repair was followed by the creation of a sigmoid loop colostomy and double-barrel ileostomy. This avoided an intrabdominal anastomosis which was felt likely to complicate due to the lady's intraoperative haemodynamic instability requiring inotropic support. This tailored management of a trans-anal small bowel evisceration through a rectal prolapse resulted in recovery and a patient who was content with her stomas and preferred to live with them rather than have continuity restored.

Phase II study of a trastuzumab biosimilar in combination with paclitaxel for HER2-positive recurrent or metastatic urothelial carcinoma: KCSG GU18-18

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) is a widely explored therapeutic target in solid tumors. We evaluated the efficacy and safety of trastuzumab-pkrb, a biosimilar of trastuzumab, in combination with paclitaxel, in HER2-positive recurrent or metastatic urothelial carcinoma (UC).

PATIENTS AND METHODS

We enrolled 27 patients; they were administered a loading dose of 8 mg/kg trastuzumab-pkrb on day 1, followed by 6 mg/kg and 175 mg/m2 paclitaxel on day 1 every 3 weeks, intravenously. All patients received six cycles of the combination treatment and continued to receive trastuzumab-pkrb maintenance until disease progression, unacceptable toxicity, or for up to 2 years. HER2 positivity (based on immunohistochemistry analysis) was determined according to the 2013 American Society of Clinical Oncology /College of American Pathologists HER2 testing guidelines. The primary endpoint was objective response rate (ORR); the secondary endpoints were overall survival (OS), progression-free survival (PFS), and safety.

RESULTS

Twenty-six patients were evaluated via primary endpoint analysis. The ORR was 48.1% (1 complete and 12 partial responses) and the duration of response was 6.9 months [95% confidence interval (CI) 4.4-9.3 months]. With a median follow-up of 10.5 months, the median PFS and OS were 8.4 months (95% CI 6.2-8.8 months) and 13.5 months (95% CI 9.8 months-not reached), respectively. The most common treatment-related adverse event (TRAE) of any grade was peripheral neuropathy (88.9%). The most common grade 3/4 TRAEs were neutropenia (25.9%), thrombocytopenia (7.4%), and anemia (7.4%).

CONCLUSIONS

Trastuzumab-pkrb plus paclitaxel demonstrates promising efficacy with manageable toxicity profiles in patients with HER2-positive recurrent or metastatic UC.

Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study

BACKGROUND

Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer.

METHODS

A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10 µg/kg/min) or phenylephrine (0.42-1.25 µg/kg/min) (each n = 10) to maintain a mean arterial pressure of 65-80 mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively.

RESULTS

After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4 ± 14.2 mL/min; p = 0.082), whereas it was reduced in the phenylephrine group (-7.9 ± 8.2 mL/min; p = 0.021). PI did not change in either group (0.4 ± 1.0 and 1.3 ± 3.1 in the norepinephrine and phenylephrine groups; p = 0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups.

CONCLUSION

During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.

Computational Investigation of Conformational Properties of Short Azapeptides: Insights from DFT Study and NBO Analysis

Azapeptides have gained much attention due to their ability to enhance the stability and bioavailability of peptide drugs. Their structural preferences, essential to understanding their function and potential application in the peptide drug design, remain largely unknown. In this work, we systematically investigated the conformational preferences of three azaamino acid residues in tripeptide models, Ac-azaXaa-Pro-NHMe [Xaa = Asn (4), Asp (5), Ala (6)], using the popular DFT functionals, B3LYP and B3LYP-D3. A solvation model density (SMD) was used to mimic the solvation effect on the conformational behaviors of azapeptides in water. During the calculation, we considered the impact of the amide bond in the azapeptide models on the conformational preferences of models 4-6. We analyzed the effect of the HB between the side-chain main chain and main-chain main-chain on the conformational behaviors of azapeptides 4-6. We found that the predicted lowest energy conformation for the three models differs depending on the calculation methods. In the gas phase, B3LYP functional indicates that the conformers tttANP-1 and tttADP-1 of azapeptides 4 and 5 correspond to the type I of β-turn, the lowest energy conformation with all-trans amide bonds. Considering the dispersion correction, B3LYP-D3 functional predicts the conformers tctANP-2 and tctADP-3 of azapeptide 4 and 5, which contain the cis amide bond preceding the Pro residue, as the lowest energy conformation in the gas phase. The results imply that azaAsx and Pro residues may involve cis-trans isomerization in the gas phase. In water, the predicted lowest energy conformer of azapeptides 4 and 5 differs from the gas phase results and depends on the calculational method. For azapeptide 6, regardless of calculation methods and phases, tttAAP-1 (β-I turn) is predicted as the lowest energy conformer. The results imply that the effect of the side chain that can form HBs on the conformational preferences of azapeptides 4 and 5 may not be negligible. We compared the theoretical results of azaXaa-Pro models with those of Pro-azaXaa models, showing that incorporating azaamino acid residue in peptides at different positions can significantly impact the folding patterns and stability of azapeptides.

Delayed immune-mediated hepatitis after three cycles of pembrolizumab for the treatment of sinonasal melanoma

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that induce the anti-tumor effects of T cells by targeting co-inhibitory immune checkpoints. The development of ICIs has revolutionized the clinical practice of oncology, leading to significant improvements in outcomes; therefore, ICIs are now standard care for various types of solid cancers. Immune-related adverse events, the unique toxicity profiles of ICIs, usually develop 4-12 weeks after initiation of ICI treatment; however, some cases can occur >3 months after cessation of ICI treatment. To date, there have been limited reports about delayed immune-mediated hepatitis (IMH) and histopathologic findings. Herein, we present a case of delayed IMH that occurred 3 months after the last dose of pembrolizumab, including histopathologic findings of the liver. This case suggests that ongoing surveillance for immune-related adverse events is required, even after cessation of ICI treatment.

Comparison of modified thoracoabdominal nerve block through perichondral approach and subcostal transversus abdominis plane block for pain management in laparoscopic cholecystectomy: a randomized-controlled trial

Background

The modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) is a novel regional analgesic technique that can provide analgesia for both the lateral and anterior abdominal walls. This study aimed to compare the analgesic effect of M-TAPA with that of the subcostal transversus abdominis plane block (TAPB) in patients undergoing laparoscopic cholecystectomy (LC).

Methods

Sixty patients scheduled to undergo elective LC were randomly assigned to receive either M-TAPA or subcostal TAPB during anesthesia induction. The primary outcome was the maximum pain intensity during movement within the first 12 hours postoperatively, measured using an 11-point numeric rating scale (NRS). Secondary outcomes included changes in NRS scores during rest, coughing, and movement, which were assessed at 1, 2, 4, 6, and 12 hours postoperatively and immediately before discharge. Additionally, postoperative nausea and vomiting, and patient satisfaction were recorded as secondary outcomes.

Results

Data from 56 patients were analyzed, and no significant difference was observed in the primary outcome between the two groups (M-TAPA: 5.5 [interquartile range (IQR): 5-7] vs . subcostal TAPB: 5 [IQR: 4-7], median difference: 0, 95% confidence interval: -1 to 1, P = 0.580). Furthermore, no significant differences in secondary outcomes were observed between the two groups.

Conclusions

No significant difference was observed in the analgesic effect between the two techniques. Consequently, further research is necessary to compare the efficacy of M-TAPA with other well-established regional analgesic techniques.

Serum neutrophil gelatinase-associated lipocalin and lactate level during surgery predict acute kidney injury and early allograft dysfunction after liver transplantation

Early allograft dysfunction (EAD) and acute kidney injury (AKI) are common and clinically important complications after liver transplantation. Serum lactate level at the end of surgery could predict EAD and neutrophil gelatinase-associated lipocalin (NGAL) is known as a biomarker for AKI after liver transplantation. The authors investigated whether the combination of these two laboratory tests could be used as an early predictor of these two complications of EAD and AKI. We reviewed cases undergoing living donor liver transplantation (n = 353). Lactate-adjusted NGAL level, a combination of these two predictors, was calculated as the sum of each value multiplied by the odds ratio for EAD or AKI. We evaluated whether this combined predictor at the end of surgery is significantly associated with both postoperative AKI or EAD. We compared the area under the receiver operating characteristic curve (AUC) between our multivariable regression models with and without NGAL, lactate, or lactate-adjusted NGAL. NGAL, lactate and lactate-adjusted NGAL are significant predictors for EAD and AKI. The regression model for EAD or AKI including lactate-adjusted NGAL showed a greater AUC (for EAD: odds ratio [OR] 0.88, 95% confidence interval [CI] 0.84-0.91; for AKI: OR 0.89, 95% CI 0.85-0.92) compared to the AUC of the models including lactate (for EAD: OR 0.84, 95% CI 0.81-0.88; for AKI: OR 0.79, 95% CI 0.74-0.83) or NGAL alone (for EAD: OR 0.82, 95% CI 0.77-0.86; for AKI: OR 0.84, 95% CI 0.80-0.88) or the model without lactate or NGAL (for EAD: OR 0.64, 95% CI 0.58-0.69, for AKI: OR 0.75, 95% CI 0.70-0.79). In conclusion, lactate-adjusted NGAL level at the end of surgery could be a reliable combined laboratory predictor for postoperative EAD or AKI after liver transplantation with a greater discriminative ability than lactate or NGAL alone.

Impact of Enhanced in-Hospital Infection Prevention During the COVID-19 Pandemic on Postoperative Pneumonia in Older Surgical Patients

Purpose

We aimed to investigate the impact of enhanced in-hospital infection prevention during the coronavirus disease 2019 (COVID-19) pandemic on postoperative pneumonia in older surgical patients.

Patients and Methods

We retrospectively reviewed the electronic medical records of consecutive patients ≥70 years who underwent elective surgery between 2017 and 2021 at our institution. All perioperative variables were retrieved from the electronic medical records. The primary outcome was new-onset postoperative pneumonia during the hospitalization period. Since February 2020, our institution implemented a series of policies to enhance infection prevention, hence patients were divided into groups according to whether they underwent surgery before or during the COVID-19 pandemic. An interrupted time series analysis was performed to evaluate the difference between pre- and post-intervention slopes of the primary outcome.

Results

Among the 29,387 patients included in the study, 10,547 patients underwent surgery during the COVID-19 pandemic. Although there was a decreasing trend of the monthly incidence rate of postoperative pneumonia compared to before the COVID-19 pandemic, there was no statistical significance in the trend (slope before COVID-19 period: β-coefficient, -0.007; 95% CI, -0.022 to 0.007).

Conclusion

Our study revealed that enhanced in-hospital infection prevention implemented to manage the COVID-19 pandemic did not significantly affect the decreasing trend of postoperative pneumonia at our institution.

Comparison of the recovery profile of remimazolam with flumazenil and propofol anesthesia for open thyroidectomy

BACKGROUND

Previous studies have consistently reported a slower recovery of consciousness following remimazolam-based total intravenous anesthesia without flumazenil than with propofol. This study aimed to compare the reversal effect of flumazenil on the recovery of consciousness after remimazolam-based total intravenous anesthesia with the propofol recovery profile.

METHODS

This prospective, single-blinded, randomized trial included 57 patients undergoing elective open thyroidectomy at a tertiary university hospital. Patients were randomly allocated to receive either remimazolam- or propofol-based total intravenous anesthesia (remimazolam group: 28 patients, propofol group: 29 patients). The primary outcome was the time from the end of general anesthesia to first eye opening (min). The secondary outcomes were the time from the end of the general anesthesia to extubation (min), initial modified Aldrete score measured at the post-anesthesia care unit, length of stay at the post-anesthesia care unit (min), occurrence of postoperative nausea and vomiting during the first 24 h postoperatively, and Korean version of Quality of Recovery-15 score at 24 h postoperatively.

RESULTS

The remimazolam group showed significantly faster first eye opening time (2.3 [interquartile range, IQR: 1.8-3.3] min vs. 5.0 [IQR: 3.5-7.8] min, median difference:-2.7 [95% confidence interval, CI: -3.7 to -1.5] min, P < 0.001) and extubation time (3.2 [IQR: 2.4-4.2] min vs. 5.7 [IQR: 4.7-8.3] min, median difference: -2.7 [97.5% CI: -5.0 to -1.6] min, P < 0.001). There were no significant differences in other postoperative outcomes.

CONCLUSIONS

The planned incorporation of flumazenil with remimazolam-based total intravenous anesthesia provided rapid and reliable recovery of consciousness.

T-cell specific antibody induction versus corticosteroid induction immunosuppression for liver transplant recipients: a meta-analysis

Corticosteroids remain the mainstay of immunosuppression for liver transplant recipients despite several serious complications including infection, hepatitis C virus (HCV) recurrence, diabetes mellitus (DM), and hypertension. We attempted to compare the safety and efficacy of T-cell specific antibody induction with complete corticosteroid avoidance. We searched MEDLINE, EMBASE, and Cochrane central library. Randomized controlled trials comparing T-cell specific antibody induction with corticosteroid induction immunosuppression were included. Our primary outcome was the incidence of biopsy-proven acute rejection. Eleven trials involving 1683 patients were included. The incidence of acute rejection was not significantly different between the antibody and steroid induction groups (risk ratio [RR] 0.85, 95% confidence interval [CI] 0.72, 1.01, P = 0.06, I² = 0%). However, T-cell specific antibody induction significantly reduced the risk of cytomegalovirus infection (RR 0.48, 95% CI 0.33, 0.70, P = 0.0002, I² = 3%), HCV recurrence (RR 0.89, 95% CI 0.80, 0.99, P = 0.03, I² = 0%), DM (RR 0.41, 95% CI 0.32, 0.54, P < 0.0001, I² = 0%) and hypertension (RR 0.71, 95% CI 0.55, 0.90, P = 0.005, I² = 35%). Trial sequential analysis for acute rejection showed that the cumulative z-curve did not cross the Trial sequential boundary and the required information size was not reached. T-cell specific antibody induction compared to corticosteroid induction seems to significantly reduce opportunistic infections including cytomegalovirus infection and HCV recurrence and metabolic complications including DM and hypertension. However, given the insufficient study power, low quality of evidence, and heterogeneous immunosuppressive regimens, our results should be cautiously appreciated.

Effects of sugammadex versus neostigmine on postoperative nausea and vomiting after general anesthesia in adult patients:a single-center retrospective study

We aimed to compare the effect of sugammadex to that of neostigmine with respect to the occurrence of postoperative nausea and vomiting (PONV) during the first 24 h following general anesthesia. This retrospective cohort study included patients who underwent elective surgery under general anesthesia in 2020 at an academic medical center in Seoul, South Korea. The exposure groups were determined according to whether the patient received sugammadex or neostigmine as a reversal agent. The primary outcome was PONV occurrence during the first 24 h postoperatively (overall). The association between the type of reversal agent and primary outcome was investigated using logistic regression while adjusting for confounding variables using stabilized inverse probability of treatment weighting (sIPTW). Of the 10,912 patients included in this study, 5,918 (54.2%) received sugammadex. Sugammadex was associated with a significantly lower incidence of overall PONV (15.8% vs. 17.7%; odds ratio, 0.87; 95% confidence interval [CI], 0.79-0.97; P = 0.010) after sIPTW. In conclusion, compared with neostigmine/glycopyrrolate, sugammadex use has a lower risk of PONV during the first 24 h following general anesthesia.

Effect of a repeated verbal reminder of orientation on emergence agitation after general anaesthesia for minimally invasive abdominal surgery: a randomised controlled trial

BACKGROUND

An orientation strategy providing repeated verbal reminders of time, place, and person has been widely used for the non-pharmacological management of delirium. We hypothesised that using this strategy could reduce emergence agitation and improve recovery profiles.

METHODS

This prospective observer-blinded RCT included male and female patients aged 18-70 yr undergoing minimally invasive abdominal surgery. During emergence from general anaesthesia, subjects in the orientation group (n=57) were provided a repeated reminder, including orientation: '(Patient's name), you are now recovering from general anaesthesia after surgery at Seoul National University Hospital, open your eyes!' via noise-cancelling headphones, whereas those in the control group (n=57) only heard their name: '(Patient's name), open your eyes!'. The primary outcome was the incidence of emergence agitation (Riker sedation agitation scale [SAS] ≥5). The incidence of dangerous agitation (SAS=7), maximal SAS score in the operating room, and recovery profile until 24 h postoperatively were evaluated as secondary outcomes.

RESULTS

The incidence of emergence agitation in the operating room was significantly lower in the orientation group than in the control group (16/57 [28.1%] vs 38/57 [66.7%]; relative risk [95% confidence interval], 0.5 [0.3-0.7]; P<0.001). The incidence of dangerous agitation (0 [0.0%] vs 10 [17.5%], P=0.001) and the median maximal SAS score (4 [4-5] vs 5 [4-6], P<0.001) were also lower in the orientation group. Secondary outcomes, other than agitation-related variables, were comparable between the two groups.

CONCLUSIONS

Repeated verbal stimulation of orientation may serve as a simple and easily applicable strategy to reduce emergence agitation after general anaesthesia.

CLINICAL TRIAL REGISTRATION

NCT05105178.

Practical strategies for the prevention and management of chronic postsurgical pain

Chronic postsurgical pain (CPSP) is a multifactorial condition that affects a significant proportion of patients undergoing surgery. The prevention and management of CPSP require the identification of preoperative risk factors to screen high-risk patients and establish appropriate perioperative pain management plans to prevent its development. Active postoperative pain management should be provided to prevent CPSP in patients with severe pain following surgery. These tasks have become important for perioperative team members in the management of CPSP. This review article provides a comprehensive overview of the latest research on the role of perioperative team members in preventing and managing CPSP. Additionally, it highlights practical strategies that can be employed in clinical practice, covering the definition and risk factors for CPSP, including preoperative, intraoperative, and postoperative factors, as well as a risk prediction model. The article also explores various treatments for CPSP, as well as preventive measures, including preemptive analgesia, regional anesthesia, pharmacological interventions, psychoeducational support, and surgical technique modification. This article emphasizes the importance of a comprehensive perioperative pain management plan that includes multidisciplinary interventions, using the transitional pain service as an example. By adopting a multidisciplinary and collaborative approach, perioperative team members can improve patient outcomes, enhance patient satisfaction, and reduce healthcare costs. However, further research is necessary to establish targeted interventions to effectively prevent and manage CPSP.

Structural analysis and prebiotic activity of exopolysaccharide produced by probiotic strain Bifidobacterium bifidum EPS DA-LAIM

Exopolysaccharide (EPS)-producing Bifidobacterium bifidum EPS DA-LAIM was isolated from healthy human feces, the structure of purified EPS from the strain was analyzed, and its prebiotic activity was evaluated. The EPS from B. bifidum EPS DA-LAIM is a glucomannan-type heteropolysaccharide with a molecular weight of 407-1007 kDa, and its structure comprises 2-mannosyl, 6-mannosyl, and 2,6-mannosyl residues. The purified EPS promoted the growth of representative lactic acid bacteria and bifidobacterial strains. Bifidobacterium bifidum EPS DA-LAIM increased nitric oxide production in RAW 264.7 macrophage cells, indicating its immunostimulatory activity. Bifidobacterium bifidum EPS DA-LAIM also exhibited high gastrointestinal tract tolerance, gut adhesion ability, and antioxidant activity. These results suggest that EPS from B. bifidum EPS DA-LAIM is a potentially useful prebiotic material, and B. bifidum EPS DA-LAIM could be applied as a probiotic candidate.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10068-022-01213-w.

Insights of Keratin geometry from Agro-industrial wastes: A comparative computational and experimental assessment

Understanding the structural properties of keratin is of great importance to managing their potential application in keratin-inspired biomaterials and its management of wastes. In this work, the molecular structure of chicken feather keratin 1 was characterized by AlphaFold2 and quantum chemistry calculation. The predicted IR spectrum of the N-terminal region of feather keratin 1, consisting of 28 amino acid residues, was used to assign the Raman frequencies of the extracted keratin. The MW of experimental samples were 6 & 1 kDa while the predicted MW (∼10 kDa) of β-keratin. Experimental analysis shows the magnetic field treatment could affect the functional and surface structural properties of keratin. The particle size distribution curve illustrates the dispersion of particle size concentration, while TEM analysis demonstrates the reduction of particle diameter to 23.71 ± 1.1 nm following treatment. High-resolution XPS analysis confirmed the displacement of molecular elements from their orbital.

Correlation between Cellular Structure Morphology and Anisotropic Yield in Additively Manufactured Stainless Steel 316L

Additively manufactured austenitic stainless steel 316L is composed of a cellular structure, which has a directionality, and is observed with a different morphology depending on the observation direction. The cellular structure morphology that appears with a high probability in grains with a specific grain orientation is determined. Taylor factor, which is calculated by considering grain orientation, is related to cellular structure morphology due to the directional cellular structure in additively manufactured austenitic stainless steel 316L. The Taylor factor affects the mechanical properties. The yield strength of additively manufactured SUS316L can be explained by the correlation between cellular structure morphology, grain orientation, and Taylor factor.

The core ionization energies calculated by delta SCF and Slater's transition state theory

The core ionization energies of the second-period and third-period elements are studied by ΔSCF and Slater's transition state (STS) theory by using Hartree-Fock (HF) and Kohn-Sham (KS) approximations. Electron correlation increases the estimated core ionization energies, while the self-interaction error (SIE) decreases them, especially for the third-period elements and is a more significant factor. As a result, while HF lacks electron correlation, it is free of SIE and reasonably predicts the core ionization energies. The core ionization energies calculated by HF STS are very close to those calculated by HF ΔSCF, showing that STS reasonably describes the relaxation of the core hole. The core ionization energies calculated by KS are particularly sensitive to the SIE of the functional used, with functionals having less SIE yielding more accurate ΔSCF core ionization energies. Consequently, BH&HLYP gives better results than B3LYP and LC-BOP since BH&HLYP is the hybrid functional with high proportion of the exact HF exchange. Although the core ionization energies are underestimated by ΔSCF due to SIE, STS gives larger core ionization energies than ΔSCF due to a concave behavior of the error curves of STS, which is also related to SIE. The mean absolute deviations of STS relative to ΔSCF, and relative to the experiment, are almost constant regardless of the nuclei among the element in the second period, and likewise among those in the third period. The systematic nature suggests that shifting the STS core ionization energies may be useful. We propose the shifted STS (1) for reproducing ΔSCF values, and the shifted STS (2) to reproduce the observed ones for KS calculations. Both schemes work quite well. The calculated results of KS ΔSCF and STS vary depending on the functional. However, the variation of each species' shifted STS (2) is very small, and all shifted STS (2) values are close to the observed ones. As the shifted STS require only one SCF calculation, they are simple and practical for predicting the core ionization energies.

Bibliometric analysis of research articles on post-herpetic neuralgia published from 1991 to 2020

Post-herpetic neuralgia (PHN) is one of the most painful diseases, which has made it a major concern for pain physicians. We aimed to quantitatively analyze the research outputs of studies on PHN published over the past 30 years using bibliometric analysis. We also aimed to analyze the research outputs of studies on interventional treatments for PHN and evaluate the academic achievements of Korean pain physicians. Bibliometric analysis was performed by searching the Web of Science database for PHN-related articles published between 1991 and 2020. Publication number, year, source, country, institution, and citation-related information were retrieved from the database. We also quantitatively analyzed publications related to interventional treatments for PHN. A total of 3285 publications were extracted from the database; 101 (3.1%) of the articles were published by South Korean authors, making South Korea the 11th in the order of countries that published the most articles. There were 185 articles on the effects of interventional treatments for PHN. South Korean authors published 30 (16.2%) articles out of these, making South Korea the 3rd in the order of countries that published the most articles on the effects of interventional treatment for PHN. Our results showed an increasing trend in the number of PHN-related publications and the academic achievements of Korean pain physicians in this field over the past 3 decades. However, the proportion of studies on interventional treatments is relatively small. Korean pain physicians need to establish academic evidence on interventional treatment to expand their role in this field and improve the outcomes of PHN patients.

Trial in progress: A phase 1, first-in-human, open-label, multicenter, dose-escalation and dose-expansion study of ASP3082 in patients with previously treated advanced solid tumors and KRAS G12D mutations

TPS764

Background: Kirsten rat sarcoma (KRAS) G12D is a point mutation observed in various cancer types including pancreatic ductal cancer, colon adenocarcinoma, and lung cancers. ASP3082 is a novel small-molecule proteolysis-targeting chimeric degrader that binds to, and selectively targets, the KRAS G12D-mutated protein for degradation via recruitment of E3 ubiquitin ligase proteins. In preclinical studies, ASP3082 selectively degraded the KRAS G12D-mutated protein and showed growth inhibitory activity in KRAS G12D-mutated cancer cells but not in KRAS -wildtype cancer cells. Notable antitumor effects of ASP3082 have been demonstrated when intravenously administered weekly in mice xenografted with KRAS G12D-mutated cancer cells. Methods: This first-in-human, open-label, multicenter, phase 1 study evaluates the safety and tolerability of ASP3082 in patients with pancreatic cancer, colorectal cancer, non-small cell lung cancer or other solid tumors. Participants with unresectable, locally advanced, or metastatic solid tumor malignancy with documented KRAS G12D mutation are eligible for enrollment. Part 1 consists of dose-escalation cohorts of 3−12 patients receiving intravenous administration of ASP3082 in a 21-day cycle. Part 2 consists of random assignment of ≤20 patients into 2 cohorts with different ASP3082 dose levels to determine the recommended phase 2 dose. Additional tumor-specific expansion cohorts may enroll ≤20 participants per tumor type. Primary endpoints will evaluate safety and tolerability as noted by dose-limiting toxicities, adverse events, serious adverse events, laboratory test results, electrocardiograms, vital signs, physical exams, and Eastern Cooperative Oncology Group performance status. Secondary endpoints will evaluate objective response rate, duration of response, disease control rate per Response Evaluation Criteria in Solid Tumors version 1.1, pharmacokinetics of single and repeated doses of ASP3082, and changes in KRAS G12D in tumor samples. Exploratory objectives will evaluate potential biomarkers that may correlate with treatment outcomes. Tumor assessment follow-up will continue for ≤45 weeks or until progressive disease. Enrollment in Cohort 1 is complete, and enrollment to Cohort 2 began in September 2022. Clinical trial information: NCT05382559 .

Zolbetuximab plus gemcitabine and nab-paclitaxel (GN) in first-line treatment of claudin 18.2–positive metastatic pancreatic cancer (mPC): Phase 2, open-label, randomized study

TPS782

Background: GN is a first-line treatment option for patients (pts) with mPC. Poor prognosis and low 5-year survival rate ( < 5%) with mPC highlight the need for new therapeutics. Claudin 18.2 (CLDN18.2), a tight junction protein expressed exclusively on normal gastric epithelial cells, is maintained during malignant transformation in gastric cancers and is frequently expressed in some carcinomas from organs that do not normally express it, such as pancreatic cancer. Zolbetuximab, a chimeric IgG1 monoclonal antibody, binds to CLDN18.2 and mediates tumor cell death through antibody-dependent cellular cytotoxicity and complement-dependent cytotoxicity. This phase 2 study (NCT03816163) will assess safety and efficacy of GN alone or with zolbetuximab in CLDN18.2-positive mPC. Methods: The study was expanded to enroll approximately 369 pts with histologically confirmed mPC and high CLDN18.2 expression (moderate-to-strong IHC staining intensity in ≥75% of tumor cells). The study included a safety lead-in that enrolled 3-12 pts to assess safety/tolerability of zolbetuximab (n = 3 at 1,000 mg/m2 on Cycle 1 Day 1 then 600 mg/m2 Q2W, then expand/de-escalate using a 3+3 design) plus GN. Dose-limiting toxicities (DLTs, defined as a specified zolbetuximab-related toxicity that occurs during DLT assessment period) will be assessed after Cycle 1 (28 days). Based on the recommended phase 2 dose (RP2D), confirmed during the safety lead-in, approximately 357 pts will be randomized 2:1 to zolbetuximab Q2W on Days 1 and 15 plus GN on Days 1, 8, and 15 of each cycle (Arm 1), or GN alone on Days 1, 8, and 15 of each cycle (Arm 2). Randomization will be stratified by ECOG performance status (0 or 1) and liver metastasis (yes or no). At sites in Japan, DLTs (assessed from Cycle 1 Day 1 to Cycle 2 Day 1) will be evaluated in ≤6 pts randomized to the RP2D in Arm 1. Pts will undergo imaging (CT/MRI) at baseline and Q8W until investigator-assessed disease progression (RECIST v1.1) or the start of another systemic anticancer treatment, whichever comes earlier. In addition to confirming the RP2D during the safety lead-in, primary objectives are to assess whether treatment with zolbetuximab plus GN, versus GN alone, improves overall survival (randomization phase) and to establish the safety/tolerability profile of zolbetuximab plus GN (across the study). Secondary endpoints include progression-free survival, objective response rate, disease control rate, duration of response, pharmacokinetics, and health-related quality of life (per protocol amendment). Descriptive statistics will be used for continuous endpoints and frequency and percentage for categorical endpoints. Original protocol enrollment completion was in October 2021. Under the expanded protocol amendment, 95 of ~140 sites in North America, Latin America, Europe, and Asia Pacific were activated. Clinical trial information: NCT03816163 .

Retrospective analysis of the feasibility and safety of external jugular vein cannulation in surgical patients

BACKGROUND

Establishing intravenous (IV) access is an essential procedure in surgical patients. External jugular vein (EJV) cannulation can be a good alternative for patients forwhom it is difficult to establish peripheral IV access. We aimed to investigate the feasibilityand safety of EJV cannulation in surgical patients.

METHODS

We performed a retrospective review of EJV cannulation in patients who underwent anesthesia for surgery at a tertiary hospital between 2010 and 2021. We collectedclinical characteristics, including EJV cannulation-related variables, from the anesthetic records. We also investigated the EJV cannulation-related complications, which included anyEJV cannulation-related complications (insertion site swelling, infection, thrombophlebitis,pneumothorax, and arterial cannulation) within 7 days after surgery, from the electronicmedical records during the hospitalization period for surgery.

RESULTS

We analyzed 9,482 cases of 9,062 patients for whom EJV cannulation was performed during anesthesia. The most commonly performed surgery was general surgery(49.6%), followed by urologic surgery (17.5%) and obstetric and gynecologic surgery (15.7%).Unplanned EJV cannulation was performed emergently during surgery for 878 (9.3%) cases.The only EJV cannulation-related complication was swelling at the EJV-cannula insertion site(65 cases, 0.7%). There was only one case of unplanned intensive care unit admission dueto swelling related to EJV cannulation.

CONCLUSIONS

Our study showed the feasibility and safety of EJV cannulation for surgical patients with difficult IV access or those who need additional large-bore IV access during surgery. EJV cannulation can provide safe and reliable IV access with a low risk of major complications in a surgical patient.

Biportal endoscopic versus microscopic discectomy for lumbar herniated disc: a randomized controlled trial

BACKGROUND CONTEXT

Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited.

PURPOSE

This study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs.

STUDY DESIGN

Prospective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial.

PATIENT SAMPLE

Sixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy.

OUTCOME MEASURES

Outcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted.

METHODS

All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events.

RESULTS

The ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups.

CONCLUSION

Biportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.

1783. Appropriateness of antibiotics use for patients with asymptomatic bacteriuria or urinary tract infection: A retrospective observational multicenter study in Korea

Background

Antibiotic resistance threatens public health worldwide, and inappropriate use of antibiotics is one of the main causes. Antibiotic use for asymptomatic bacteriuria (ABU) has been defined as “antibiotics never events”, and urinary tract infection (UTI) is one of the most common infectious diseases for which antibiotics are prescribed in Korea. To establish an effective antimicrobial stewardship strategy, a qualitative assessment of antibiotic use in actual clinical syndrome is necessary.

Methods

Cases of positive urine cultures (≥10⁵ CFU/ml), performed in inpatient, outpatient, and emergency departments in April 2021 were screened in 26 hospitals located throughout Korea. Cases were classified into ABU, lower UTI, and upper UTI. The appropriateness of antibiotic use was retrospectively evaluated by infectious disease specialists using quality indicators based on the domestic clinical guideline for ABU and UTI. Figure 1.

Potential Probiotic Properties of Exopolysaccharide-Producing Lacticaseibacillus paracasei EPS DA-BACS and Prebiotic Activity of Its Exopolysaccharide

Exopolysaccharide (EPS)-producing Lacticaseibacillus paracasei EPS DA-BACS was isolated from healthy human feces and its probiotic properties, as well as the structure and prebiotic activity of the EPS from this strain were examined. EPS from L. paracasei EPS DA-BACS had a ropy phenotype, which is known to have potential health benefits and is identified as loosely cell-bounded glucomannan-type EPS with a molecular size of 3.7 × 10⁶ Da. EPS promoted the acid tolerance of L. paracasei EPS DA-BACS and provided cells with tolerance to gastrointestinal stress. The purified EPS showed growth inhibitory activity against Clostridium difficile. L. paracasei EPS DA-BACS cells completely inhibited the growth of Bacillus subtilis, Pseudomonas aeruginosa, and Aspergillus brasiliensis, as well as showed high growth inhibitory activity against Staphylococcus aureus and Escherichia coli. Treatment of lipopolysaccharide-stimulated RAW 264.7 cells with heat-killed L. paracasei EPS DA-BACS cells led to a decrease in the production of nitric oxide, indicating the anti-inflammatory activity of L. paracasei EPS DA-BACS. Purified EPS promoted the growth of Lactobacillus gasseri, Bifidobacterium bifidum, B. animalis, and B. faecale which showed high prebiotic activity. L. paracasei EPS DA-BACS harbors no antibiotic resistance genes or virulence factors. Therefore, L. paracasei EPS DA-BACS exhibits anti-inflammatory and antimicrobial activities with high gut adhesion ability and gastrointestinal tolerance and can be used as a potential probiotic.

Stachydrine alleviates lipid-induced skeletal muscle insulin resistance via AMPK/HO-1-mediated suppression of inflammation and endoplasmic reticulum stress

OBJECTIVE

Insulin resistance develops due to skeletal muscle inflammation and endoplasmic reticulum (ER) stress. Stachydrine (STA), extracted from Leonurus heterophyllus, has been shown to suppress proliferation and induce apoptosis in breast cancer cells and exert anti-inflammatory properties in the brain, heart, and liver. However, the roles of STA in insulin signaling in skeletal muscle remain unclear. Herein, we examined the impacts of STA on insulin signaling in skeletal muscle under hyperlipidemic conditions and its related molecular mechanisms.

METHODS

Various protein expression levels were determined by Western blotting. Levels of mouse serum cytokines were measured by ELISA.

RESULTS

We found that STA-ameliorated inflammation and ER stress, leading to attenuation of insulin resistance in palmitate-treated C2C12 myocytes. STA dose-dependently enhanced AMPK phosphorylation and HO-1 expression. Administration of STA attenuated not only insulin resistance but also inflammation and ER stress in the skeletal muscle of high-fat diet (HFD)-fed mice. Additionally, STA-ameliorated glucose tolerance and insulin sensitivity, as well as serum TNFα and MCP-1, in mice fed a HFD. Small interfering (si) RNA-associated suppression of AMPK or HO-1 expression abolished the effects of STA in C2C12 myocytes.

CONCLUSIONS

These results suggest that STA activates AMPK/HO-1 signaling, resulting in reduced inflammation and ER stress, thereby improving skeletal muscle insulin resistance. Using STA as a natural ingredient, this research successfully treated insulin resistance and type 2 diabetes.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

Background

It is unclear whether and how diabetes mellitus may aggravate myocardial fibrosis and remodeling in the pressure-overloaded heart. We investigated the impact of diabetes on the prognosis of aortic stenosis (AS) patients and its underlying mechanisms using comprehensive noninvasive imaging studies and plasma proteomics.

Methods

Severe AS patients undergoing both echocardiography and cardiovascular magnetic resonance (CMR) (n=253 of which 66 had diabetes) comprised the imaging cohort. The degree of replacement and diffuse interstitial fibrosis by late gadolinium enhancement (LGE) and extracellular volume fraction (ECV) was quantified using CMR. Plasma samples were analyzed with the multiplex proximity extension assay for 92 proteomic biomarkers in a separate biomarker cohort of severe AS patients (n=100 of which 27 had diabetes).

Results

In the imaging cohort, diabetic patients were older (70.4±6.8 vs. 66.7±10.1 years) and had a higher prevalence of ischemic heart disease (28.8% vs. 9.1%), with more advanced ventricular diastolic dysfunction. On CMR, diabetic patients had increased replacement and diffuse interstitial fibrosis (LGE% 0.3 [0.0–1.6] versus 0.0 [0.0–0.5], p=0.009; ECV% 27.9 [25.7–30.1] versus 26.7 [24.9–28.5], p=0.025) (Figure 1).

Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) are significantly elevated in diabetic AS patients (Figure 2). Pathway over-representation analyses of the plasma proteomics with Gene Ontology terms indicated that pathways related to inflammatory response and extracellular matrix components were enriched, suggesting that diabetes is associated with systemic effects that evoke proinflammatory and profibrotic response to the pressure-overloaded myocardium.

During follow-up (median 6.3 years [IQR 5.2–7.2]) of the imaging cohort, 232 patients received aortic valve replacement (AVR) with 53 unexpected heart failure admissions or death. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and AVR (hazard ratio 1.88, 95% confidence interval 1.06–3.31, p=0.030).

Conclusion

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory and profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Research Foundation of Korea

Augmented risk of ischemic stroke in hypertrophic cardiomyopathy patients without documented atrial fibrillation

Background

Ischemic stroke is a common complication in patients with hypertrophic cardiomyopathy (HCM) (1). Although atrial fibrillation (AF) is a well-established risk factor for ischemic stroke in HCM, the risk of ischemic stroke in patients with HCM without documented AF is less recognized (1, 2). This study aimed to determine the risk of ischemic stroke and identify its risk factors in patients with HCM without documented AF.

Methods

This nationwide population-based cohort study used the Korean National Health Insurance database. After excluding patients with a prior history of AF, thromboembolic events, cancer, or the use of anticoagulants, we identified 8,328 HCM patients without documented AF and 1:2 propensity score-matched 16,656 non-HCM controls. The clinical outcome was an incident ischemic stroke.

Results

During a mean follow-up of approximately 6 years, ischemic stroke occurred in 328/8,328 (3.9%) patients with HCM and 443/16,656 (2.7%) controls. Among individuals who developed ischemic stroke, the proportion of AF concomitantly detected accounted for 26.5% (87/328) and 5.8% (26/443) in the HCM and control groups, respectively. The overall incidence of ischemic stroke was 0.716/100 person-years in the HCM group, which was significantly higher than that in the control group (0.44/100 person-years) (HR 1.643; 95% CI, 1.424–1.895; P&lt;0.001, Figure 1). The subgroup analysis according to age, sex, and comorbidities (chronic heart failure, hypertension, dyslipidemia, and vascular disease) consistently demonstrated a higher risk of ischemic stroke in the HCM group (P for interaction &gt;0.05). In the HCM group, age ≥65 years (adjusted hazard ratio [HR] 2.741; 95% confidence interval [CI], 2.156–3.486; P&lt;0.001) and chronic heart failure (adjusted HR 1.748; 95% CI, 1.101–2.745; P=0.018) were independent risk factors for ischemic stroke. Overall incidence was 1.360/100 in patients with HCM aged ≥65 and 2.315/100 person-years years in those with chronic heart failure, respectively. Also, compared to controls aged &lt;65 years and without CHF, adjusted HR for ischemic stroke was 4.756 (95% CI 3.807–5.867) in patients with HCM aged ≥65 years and 2.539 (95% CI 1.638–3.936) in those with CHF, respectively (Figure 2).

Conclusions

Patients with HCM without documented AF are at a higher risk of ischemic stroke than the propensity score-matched general population. Age ≥65 years and chronic heart failure are two strong independent risk factors for ischemic stroke in this population.

Funding Acknowledgement

Type of funding sources: None.

Effects of the Energy Density on Pores, Hardness, Surface Roughness, and Tensile Characteristics of Deposited ASTM 316L Specimens with Powder-Bed Fusion Process

Powder bed fusion (PBF) is a typical metal-AM process. Studies on the process parameters are required to fabricate the desired shape without defects in the PBF process. The aim of this study is to investigate the effects of energy density on the pore, hardness, surface roughness, and tensile characteristics of deposited ASTM 316L specimens using a powder-bed fusion process. Twenty-seven types of specimens with different laser powers, scanning speeds, and overlap ratios were fabricated using the PBF process. The effects of the energy density on the porosity, hardness, surface roughness, tensile strength, and fracture properties of ASTM 316L specimens were examined. The relationships between these properties and energy density are discussed. A critical energy density level was suggested as 79 J/mm³ considering these characteristics. With the critical energy density level, relative density, surface roughness (Ra) and hardness were observed 99.5%, 1.2 μm, and 240 HV, respectively. Additionally, these characteristics were improved with increasing energy density. Five representative conditions were chosen to fabricate tensile specimens with the ASTM 316L powder through the PBF process. Tensile characteristics, including ultimate strength, yield strength, strain, and fracture shape, were examined for different energy densities. The best tensile characteristics were observed with the highest energy density level of 155 J/mm³.

Atomistic deformation mechanism of silicon under laser-driven shock compression

Silicon (Si) is one of the most abundant elements on Earth, and it is the most widely used semiconductor. Despite extensive study, some properties of Si, such as its behaviour under dynamic compression, remain elusive. A detailed understanding of Si deformation is crucial for various fields, ranging from planetary science to materials design. Simulations suggest that in Si the shear stress generated during shock compression is released via a high-pressure phase transition, challenging the classical picture of relaxation via defect-mediated plasticity. However, direct evidence supporting either deformation mechanism remains elusive. Here, we use sub-picosecond, highly-monochromatic x-ray diffraction to study (100)-oriented single-crystal Si under laser-driven shock compression. We provide the first unambiguous, time-resolved picture of Si deformation at ultra-high strain rates, demonstrating the predicted shear release via phase transition. Our results resolve the longstanding controversy on silicon deformation and provide direct proof of strain rate-dependent deformation mechanisms in a non-metallic system.

Understanding the how silicon deforms under pressure is important for several fields, including planetary science and materials design. Laser-driven shock compression experiments now confirm that shear stress generated during compression is released via a high-pressure phase transition.

Effect of Continuous Infusion of Intravenous Nefopam on Postoperative Opioid Consumption After Video-assisted Thoracic Surgery: A Double-blind Randomized Controlled Trial

BACKGROUND

Although nefopam has been reported to have opioid-sparing and analgesic effects in postsurgical patients, its effectiveness in video-assisted thoracoscopic surgery (VATS) is unknown.

OBJECTIVES

This study aimed to investigate the opioid-sparing and analgesic effects of perioperative nefopam infusion for lung resection.

STUDY DESIGN

Double-blinded randomized controlled trial.

SETTING

Operating room, postoperative recovery room, and ward at a single tertiary university hospital.

METHODS

Ninety patients scheduled for elective VATS for lung resection were randomized to either the nefopam (group N) or control group (group C). Group N received 20 mg nefopam over 30 minutes immediately after the induction of anesthesia. Nefopam was administered continuously for 24 hours postoperative, using a dual-channel elastomeric infusion pump combined with fentanyl-based intravenous patient-controlled analgesia. Group C received the same volume of normal saline as nefopam solution administered in the same manner. The primary outcome measure was fentanyl consumption for the first postoperative 24 hours. The secondary outcome measures were the cumulative fentanyl consumption during the first postoperative 48 hours, pain intensity at rest and during coughing evaluated using an 11-point numeric rating scale, quality of recovery at postoperative time points 24 hours and 48 hours, and the occurrence of analgesic-related side effects during the first postoperative 24 hours and postoperative 24 to 48 hour period. Variables related to chronic postsurgical pain (CPSP) were also investigated by telephone interviews with patients at 3 months postoperative. This prospective randomized trial was approved by the appropriate institutional review board and was registered in the ClinicalTrials.gov registry.

RESULTS

A total of 83 patients were enrolled. Group N showed significantly lower fentanyl consumption during the first postoperative 24 hours and 48 hours (24 hours: median difference: -270 µg [95%CI, -400 to -150 µg], P < 0.001); 48 hours: median difference: -365 µg [95% CI: -610 to -140 µg], P < 0.001). Group N also showed a significantly lower pain score during coughing at 24 hours postoperative (median difference, -1 [corrected 95% CI: -2.5 to 0], adjusted P = 0.040). However, there were no significant between-group differences in the postoperative quality of recovery, occurrence of analgesic-related side effects, length of hospital stay, and occurrence of CPSP.

LIMITATIONS

Despite the significant opioid-sparing effect of perioperative nefopam infusion, it would have been difficult to observe significant improvements in other postoperative outcomes owing to the modest sample size.

CONCLUSION

Perioperative nefopam infusion using a dual-channel elastomeric infusion pump has a significant opioid-sparing effect in patients undergoing VATS for lung resection. Therefore, it could be a feasible option for multimodal analgesia in these patients.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Retrospective analysis of the incidence and predictors of postoperative nausea and vomiting after orthopedic surgery under spinal anesthesia

Background

Postoperative nausea and vomiting (PONV) commonly occurs after spinal anesthesia; however, its incidence rate and predictors have been scarcely studied. Therefore, we aimed to investigate its incidence rate and potential predictors.

Methods

The electronic medical records of 6,610 consecutive patients undergoing orthopedic surgery under spinal anesthesia were reviewed between January 2016 and December 2020. The primary outcome was PONV incidence within 24 h after spinal anesthesia. Along with its incidence rate, we investigated its predictors using multivariable logistic regression analysis.

Results

Among the 5,691 patients included in the analysis, 1,298 (22.8%) experienced PONV within 24 h after spinal anesthesia. Female sex (odds ratio [OR] = 3.18; 95% confidence interval [CI], 2.67-3.78; P < 0.001), nonsmoker (OR = 2.13; 95% CI, 1.46-3.10; P < 0.001), history of PONV (OR = 1.53; 95% CI, 1.27-1.84; P < 0.001), prophylactic 5-HT3R antagonist use (OR = 0.35; 95% CI, 0.24-0.50; P < 0.001), prophylactic steroid use (OR = 0.53; 95% CI, 0.45-0.63; P < 0.001), baseline heart rate ≥ 60 beats/min (OR = 1.36; 95% CI, 1.09-1.70, P = 0.007), and postoperative opioid use (OR = 2.57; 95% CI, 1.80-3.67; P < 0.001), were significant predictors of the primary outcome.

Conclusions

Our study showed the common incidence of PONV after spinal anesthesia and its significant predictors. A better understanding of its predictors may provide important information for its management.

Radiographic progression in the absence of prostate-specific antigen (PSA) progression in patients with metastatic hormone-sensitive prostate cancer (mHSPC): Post hoc analysis of ARCHES

5072

Background: Enzalutamide (ENZA) + androgen deprivation therapy (ADT) significantly reduced the risk of radiographic progression and increased overall survival in men with mHSPC, regardless of baseline PSA levels (ARCHES; NCT02677896). This post hoc analysis investigated concordance between PSA progression and radiographic progression in patients with mHSPC. Methods: Patients with mHSPC (n=1150) were randomized 1:1 to ENZA (160 mg/day) + ADT or placebo (PBO) + ADT. The concordance between radiographic progression and PSA progression, as defined by Prostate Cancer Clinical Trials Working Group 2 (PCWG2) criteria, and between any rise in PSA above nadir was assessed. Results: In total, 267/1150 patients in ARCHES had radiographic progression (ENZA + ADT, n=79; PBO + ADT, n=188). At radiographic progression, the median (range) PSA for ENZA + ADT-treated patients was 2.25 ng/mL (0–1062.3 ng/mL) and 17.47 ng/mL (0–1779.5 ng/mL) for PBO + ADT-treated patients. Most patients (67%) treated with ENZA + ADT did not have PCWG2-defined PSA progression at radiographic progression, compared with 43% of those treated with PBO + ADT (Table). The median absolute and percentage rise in PSA from nadir to radiographic progression was 0.77 ng/mL and 200%, respectively, with ENZA + ADT compared with 12.23 ng/mL and 367%, respectively, with PBO + ADT. Conclusions: In this post hoc analysis of ARCHES, we found frequent discordance between radiographic progression and PSA progression by PCWG2 criteria or any PSA rise over nadir in patients with mHSPC treated with ENZA + ADT. Thus, regular imaging is recommended to detect radiographic progression among patients treated with potent androgen receptor pathway inhibitors, such as ENZA + ADT, as serial PSA monitoring alone may not be sufficient to detect radiographic progression in many patients. Clinical trial information: NCT02677896. [Table: see text]