This study aimed to identify barriers and facilitators affecting implementation of perioperative music interventions in general practice. A qualitative implementation study using semistructured interviews. The updated Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. The domains used were: innovation, outer setting, inner setting and individuals. Primary outcomes were barriers and facilitators for the implementation of perioperative music interventions in general practice. General practices in the Netherlands. Dutch general practitioners. 15 participants were included, among which 11 general practice owners, one salaried general practitioner, two locum general practitioners and one general practitioner in training. In total, 19 key barriers and 34 key facilitators were identified. For the innovation domain, a lack of research conducted in primary care and low awareness of the intervention were considered barriers whereas user-friendliness and low costs were seen as facilitators. For the outer setting domain, no barriers were identified and possibilities for external financing, inclusion in clinical guidelines and patient and media pressure were considered facilitators. For the inner setting, the lack of readily accessible information aimed at primary care was seen as a barrier, whereas a shared belief in minimising perioperative pain and anxiety was seen as a facilitator. For the individuals domain, a pre-existing heavy workload and understaffing were seen as barriers, whereas the autonomous role of general practitioners was seen as a facilitator. Several key barriers and facilitators for implementation of perioperative music interventions in general practice were identified. A lack of research performed in the setting of primary care of the efficacy of the music intervention and low awareness among general practitioners were examples of barriers. Notable facilitators were user-friendliness, low-costs and the autonomous position of the general practitioner. Implementation of music intervention by general practitioners seems feasible, yet there is still room for more research to be performed in the specific context of primary care.
Bedside gastric ultrasound provides information about the content and volume of the stomach, helping stratify the perioperative aspiration risk. We aimed to assess the intra- and interrater reliability of antral cross-sectional area (CSA) measurements, performed by anesthesiologists with different expertise levels, in patients with term pregnancy before elective Cesarean delivery. We conducted a prospective study on patients with term pregnancy at ≥ 37 weeks gestational age who were scheduled for elective Cesarean delivery under neuraxial anesthesia and who had been following institutional fasting guidelines. The raters were four anesthesiologists with two levels of expertise (two experienced and two novice). Each participant was assessed by two raters, one of each level of expertise, in a random order with both raters blinded to each other's assessments. A standardized technique was employed using a portable ultrasound system with patients in the supine position and then in the right lateral decubitus (RLD) position. Three measurements were taken in each position by each rater. The primary outcome was the antral CSA, used to calculate the intra- and interrater reliability between the two levels of expertise. Secondary outcomes included the qualitative assessment of the antrum and volume estimation of the stomach (mL, mL·kg-1). Of 30 enrolled participants, two were excluded, leaving 28 for analysis. The median antral CSA was 4.7 cm2 and 8.4 cm2 in the supine and RLD positions, respectively. The intraclass correlation coefficient (ICC) for the intrarater reliability was "good" to "excellent" (ICC, 0.88; 95% confidence interval lower limit [CI LL], 0.80), irrespective of the level of expertise and examination position. Between the two levels of expertise, the interrater reliability was "moderate" in the supine position (ICC, 0.52; 95% CI LL, 0.2) and "poor" in the RLD position (ICC, 0.47; 95% CI LL, 0.14). The interrater reliability between the novice and experienced raters for the antral grade (0-2) was moderate (kappa = 0.50). The volume estimation was similar in both levels of expertise. There was 71% (95% CI LL, 51) agreement among raters at determining a CSA ≤ 10 cm2 in the RLD position, with an overall underestimation of the measurements in novice raters. Experienced and novice anesthesiologists performing bedside gastric ultrasound showed "good" to "excellent" intrarater reliability. Nevertheless, interrater reliability was "poor" to "moderate". Clinically, the volume estimation of the stomach yielded similar results among raters. This study highlights the challenge of transferring gastric ultrasound skills to novice operators while also underscoring the importance of continued practice among experienced ones. RéSUMé: OBJECTIF: L'échographie gastrique au chevet fournit des informations sur le contenu et le volume de l’estomac, facilitant ainsi la stratification du risque d’inhalation périopératoire. Nous avons cherché à évaluer la concordance intra- et interévaluateur des mesures de la surface de coupe transversale (SCT) de l’antre gastrique, réalisées par des anesthésiologistes de différents niveaux d’expertise, chez des personnes en fin de grossesse avant une césarienne programmée. MéTHODE: Nous avons mené une étude prospective auprès de personnes parturientes à ≥ 37 semaines d'âge gestationnel, devant bénéficier d’une césarienne programmée sous anesthésie neuraxiale et ayant respecté les directives institutionnelles de jeûne préopératoire. L’évaluation a été réalisée par quatre anesthésiologistes répartis en deux niveaux d’expertise (deux personnes expérimentées et deux novices). Chaque personne parturiente a été évaluée par deux anesthésiologistes, un de chaque niveau d’expertise, dans un ordre aléatoire, chaque anesthésiologiste étant en aveugle quant aux mesures de l’autre. Une technique normalisée a été utilisée au moyen d’un appareil d'échographie portatif, en décubitus dorsal puis en décubitus latéral droit (DLD). Trois mesures ont été effectuées dans chaque position par chaque anesthésiologiste. Le critère d’évaluation principal était la SCT de l’antre gastrique, utilisée pour calculer la concordance intra- et interévaluateur entre les deux niveaux d’expertise. Les critères d’évaluation secondaires comprenaient l'évaluation qualitative de l’antre et l’estimation du volume de l’estomac (mL, mL·kg−1). RéSULTATS: Sur 30 personnes parturientes incluses, deux ont été exclues, laissant 28 cas pour l’analyse. La SCT antrale médiane était de 4,7 cm2 en décubitus dorsal et de 8,4 cm2 en DLD. Le coefficient de corrélation intraclasse (CCI) pour la concordance intraévaluateur était « bon » à « excellent » (CCI : 0,88; limite inférieure de l’intervalle de confiance [LI IC] à 95 % : 0,80), quel que soit le niveau d’expertise ou la position d’examen. Entre les deux niveaux d’expertise, la concordance interévaluateur était « modérée » en décubitus dorsal (CCI : 0,52; LI IC 95 % : 0,2) et « faible » en DLD (CCI : 0,47; LI IC 95 % : 0,14). La concordance interévaluateur entre les personnes novices et expérimentées pour la classification antrale (0–2) était modérée (kappa = 0,50). L’estimation du volume était similaire entre les deux niveaux d’expertise. Un accord de 71 % (LI IC 95 % : 51) a été observé entre les anesthésiologistes pour déterminer qu’une SCT ≤ 10 cm2 en DLD, avec une sous-estimation globale des mesures chez les novices. CONCLUSION: Les anesthésiologistes expérimentés et novices réalisant une échographie gastrique au chevet ont affiché une concordance intraévaluateur « bonne » à « excellente ». La concordance interévaluateur était toutefois « faible » à « modérée ». Sur le plan clinique, l’estimation du volume de l’estomac a donné des résultats similaires d’un niveau d’expertise à l’autre. Cette étude met en lumière la difficulté de transmettre les compétences en échographie gastrique aux opérateurs novices, tout en soulignant l’importance d’une pratique continue chez les opérateurs expérimentés.
Gabapentinoids are increasingly being prescribed in older adults (aged 60 years or older), but concerns have been raised that their adverse effects on the CNS can increase the risk of fractures. Previous studies have reported associations between gabapentinoid use and fracture, but many have not adequately addressed confounding by indication or examined risk across the treatment journey. Therefore, we aimed to investigate the temporal association between gabapentinoid treatment and fracture in older adults, and to assess whether concomitant opioid or benzodiazepine use further modifies this risk. In this retrospective multinational population-based study, we used data from the UK Clinical Practice Research Datalink (CPRD) Aurum database and the South Korea National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS). The analysis included individuals aged 60 years or older prescribed a gabapentinoid and who had a hospitalised fracture between Jan 1, 2010, and Dec 31, 2020, in the UK and between Jan 1, 2003, and Dec 31, 2019, in South Korea. The observation period for each included individual was divided into four mutually exclusive windows: 90 days before gabapentinoid treatment (pre-exposure window), first 60 days of treatment period (focal window 1), remaining time of the treatment period (focal window 2), and all other non-treatment periods (referent window), to capture how risk varied across the treatment course. Adjusted incidence rate ratios (aIRRs) with 95% CI of fracture during different risk windows were estimated using conditional Poisson models within each country, and the country-specific aIRRs for the same risk window were then pooled using a random-effects model. We included 20 030 participants in CPRD and 2935 in NHIS-HEALS in the analysis. In the CPRD cohort, 15 366 (76·7%) were women and the mean age at event was 77·85 years. In the NHIS-HEALS cohort, 2007 (68·4%) were women and the mean age at event was 69·24 years. The pooled results showed an increased risk of fracture during the pre-exposure window (aIRR 2·92, 95% CI 1·61-5·28, p=0·0004). The aIRR was 1·31 (95% CI 1·00-1·71, p=0·051) in the first 60 days of the treatment period and did not increase for the remainder of the treatment period (0·84, 0·54-1·32, p=0·45). Concurrent prescription of opioids or benzodiazepines elevated the risk of fracture, with an aIRR of 3·15 (95% CI 2·85-3·48, p<0·0001) for opioids and 1·91 (1·50-2·44, p<0·0001) for benzodiazepines during the first 60 days of gabapentinoid treatment period. The risk of fracture was the highest in the period before the commencement of gabapentinoid treatment and declined after initiation of treatment. The results do not support a sustained causal relationship between gabapentinoid use and risk of fracture in older adults but warrant fall and fracture-prevention measures around gabapentinoid initiation. The elevated fracture risk observed with concomitant opioid or benzodiazepine use highlights the need for careful review of concurrent sedating medicines when initiating gabapentinoids. UK National Institute for Health and Care Research; Hong Kong Innovation and Technology Commission; Ministry of Food and Drug Safety, South Korea.
Assessment of long-term patient-reported outcome allows identification of vulnerable populations undergoing cardiac surgery. Incorporation of findings into clinical practice may enhance risk-stratification, prevent perioperative complications, and improve outcome. Frailty is prevalent in up to a third of cardiac patients and peri-procedural programs addressing frailty and delirium may be relevant to long-term quality-of-life. This prospective study aims to identify predictors of health-related quality-of-life (HR-QoL) one year after cardiac surgery and assess outcome in patients enrolled in an extensive frailty- and delirium-pathway. Patients undergoing cardiac surgery at a high-volume German heart center were enrolled in an anesthesiology quality registry and health-related quality of life was assessed using the Short Form-12 (SF-12) questionnaire at 1-year-follow-up. Corresponding factors were analyzed for their association with individual outcome. The cohort comprised 812 patients. A subgroup of 190 patients participated in a frailty and delirium management program, providing extended preoperative screening and postoperative supervision. Female sex [B -2.59, 95% CI (-4.39 - -0.78), p = 0.005], increase in age [B -3.1, 95% CI (-5.34 - -0.86), p = 0.007] and weight [B -3.97, 95% CI (-6.03 - -1.91), p < 0.001], preoperative anemia [B -3.21, 95% CI (-5.64 - -0.77), p = 0.01], history of smoking [B -3.0, 95% CI (-5.39 - -0.6), p = 0.014], failure to extubate after 8 hours of postoperative ventilation [B -1.82, 95% CI (-3.36 - -0.28), p = 0.021], postoperative acute kidney injury [B -2.18 (95% CI -4.22 - -0.14), p = 0.037] and physical frailty [B -9.88, 95% CI (-18.28 - -1.49), p = 0.021] were independently associated with lower physical outcome scores. Cognitive scores were higher in older patients [B 4.08, 95% CI (1.57-6.59), p = 0.001] and lower in smokers [B -2.43, 95% CI (-4.34 - -0.51), p = 0.013]. Independent predictors of impaired HR-QoL at 1-year follow-up could be identified, suggesting a phenotype at risk. Physical frailty independently predicted poorer physical outcome, emphasizing potential for prehabilitation and frailty-management. Findings should be interpreted considering selection- and response-bias and absence of baseline HR-QoL-assessment. This observational study complied with the Declaration of Helsinki and was approved by the Ethics Committee of the Medical Faculty of the Ruhr-University Bochum on 17th November 2022 (Registration-Number: 2022 - 947). Minor additions to the questionnaire were approved on 19th August 2024 (Registration-Number: 2022 - 947_1).
Studies assessing the impact of advanced practice providers (APPs), including nurse practitioners and physician assistants, have demonstrated a similar quality of care for patients admitted to the hospital for medical diagnoses. However, no studies have examined the relationship between APP integration and morbidity after cancer surgery. This study assesses the relationship between APP staffing intensity and patient outcomes following major abdominal cancer surgery. We used 100% national Medicare data (2010-2019) to assess the link between APP staffing intensity and surgical outcomes for patients undergoing major abdominal cancer surgery, including cystectomy, colectomy, hepatectomy, esophagectomy, gastrectomy, and pancreatectomy. The primary exposure was the ratio of APPs per 100 hospital beds, and patients were empirically divided into tertiles. Outcomes included readmission rates and length of stay, adjusted for patient and hospital level factors. As a secondary outcome, we measured 30-day perioperative mortality. We analyzed 326,547 colectomy patients, 50,400 cystectomy patients, 14,112 esophagectomy patients, 27,152 gastrectomy patients, 15,225 hepatectomy patients, and 46,287 pancreatectomy patients. Surgery at centers with the most advanced practice providers per beds (i.e., the highest tertile) was associated with shorter length of stays for most surgery types analyzed. Unadjusted 30-day readmissions tended to be lower in patients undergoing more complex procedures, such as esophagectomy (21.5% vs. 24.3%; p = 0.006) but not for the less complex operations studied, such as colectomy (13.6% vs. 13.5%; p = 0.22). However, clinical differences in outcomes were lost on analyses controlling for patient and hospital factors (IRR length of stay: 0.98-1.01; p = 0.002-087) (OR readmissions: 0.86-1.01; p = 0.003-0.80). The relationship between hospital APP staffing intensity and surgical outcomes was varied and heterogenous. However, differences in outcomes were primarily explained by hospital factors. More work is needed to determine process measures associated with the deployment of inpatient APPs.
This study evaluated the impact of a dedicated perioperative nursing team on operating theatre efficiency in robotic-assisted spinal surgery. A structured training programme was developed for a team of four perioperative nurses to achieve competence and autonomy in robotic system management across all phases of care. Operative data were retrospectively collected and compared between a pre-implementation phase and a post-implementation phase. A total of 130 robotic-assisted spinal procedures were analysed, including 47 performed before and 83 after team implementation. Following introduction of the specialised nursing team, mean time to surgical start decreased from 67.5 to 61.1 min, and overall operative duration was significantly reduced from 253.9 to 195.0 min. Implant execution time remained stable (30.0 min) despite a significant increase in the mean number of pedicle screws implanted per procedure from 4.9 to 6.4. Efficiency per screw improved markedly, with time per screw decreasing from 7.0 to 4.8 min. Three robotic procedures were abandoned in the pre-implementation period due to workflow-related issues, whereas no procedures were abandoned after introduction of the dedicated team. These findings demonstrate that the implementation of a specialised perioperative nursing team is associated with substantial improvements in workflow efficiency in robotic-assisted spinal surgery.
Giant cell tumor of bone (GCTB), osteosarcoma, and Ewing sarcoma represent the most characteristic primary bone neoplasms, and optimization of their diagnostic and therapeutic strategies remains a research priority in the field of bone and soft tissue oncology. The National Comprehensive Cancer Network (NCCN) released the Clinical Practice Guidelines in Bone Cancer (Version 2.2026), introducing key evidence-based updates spanning equivalent biological therapy alternatives, perioperative chemotherapy conceptual restructuring, expanded management strategies for recurrent/progressive disease, refined molecular diagnostic protocols, fertility preservation, and standardization of rare subtype treatment. This article systematically interprets the revision highlights of this guideline, integrates recent high-level clinical research evidence, analyzes its evidence-based foundation and clinical translation pathway, and compares it with relevant domestic diagnostic and therapeutic standards to provide academic reference for multidisciplinary standardized management of bone tumors in China. 骨巨细胞瘤、骨肉瘤及尤文肉瘤是原发性骨肿瘤中最具代表性的瘤种，其诊疗策略的优化始终是骨与软组织肿瘤领域的研究重点。美国国家综合癌症网络（NCCN）发布的《2026年第2版骨肿瘤临床实践指南》在生物治疗等效替代、围术期化疗理念重构、复发/进展处置策略拓展、分子诊断体系完善、生育力保护及罕见亚型规范化治疗等核心维度形成了关键循证更新。本文系统解读该指南的修订要点，结合近年高级别临床研究证据，分析其循证医学基础与临床转化路径，并与国内相关诊疗规范进行对比，旨在为我国骨肿瘤多学科规范化诊疗提供学术参考。.
This is Part II of a Society for the Advancement of Transplant Anesthesia white paper providing evidence-based recommendations for the use of point-of-care ultrasound (PoCUS) during and after abdominal organ transplantation. The white paper was developed by experts in abdominal transplant anesthesia and critical care after review of the current literature and practice behaviors. The recommendations are organized by phase of care: preoperative, intraoperative, and postoperative. In Part II, we focus on the use of PoCUS in the immediate postoperative and intensive care setting to guide fluid management, recognize venous congestion, identify causes of acute kidney injury and shock, estimate hemodynamics, and screen for increased intracranial pressure after abdominal organ transplantation.
Core outcome measurement sets (COMS) enhance the consistency and comparability of outcome reporting in clinical research. However, their effectiveness depends on the selection of valid, reliable, and feasible measurement instruments. Core outcome sets (COS) and COMS have been developed for specific intensive care unit (ICU) patient subgroups. The aim of this study is to establish a standardised approach to outcome measurement and operationalisation for adults acutely admitted to the ICU who are participating in clinical trials and other clinical research. This protocol describes the development of a COMS for adults acutely admitted to the ICU, the CoreMS-ICU, consisting of six core outcomes: survival, free of life support, free of delirium, out of hospital, health-related quality of life, and cognitive function. We will follow the Consensus-based Standards for the Selection of Health Measurement Instruments guideline and report according to the Core Outcome Set-STAndardised Protocol Items guideline. The development of the CoreMS-ICU will follow five predefined steps: (1) conceptual considerations for the six core outcomes; (2) systematic searches for outcome measurement instruments, including consideration of existing COMS; (3) quality assessment of relevant outcome measurement instruments; (4) consensus-based selection of outcome measurement instruments; and (5) recommendations and guidance on how to operationalise and report the measurement of the six core outcomes. We will involve research panels consisting of key stakeholders: patients, family members, healthcare professionals, and researchers in steps 1 and 4. We aim to develop a COMS for adults acutely admitted to ICU patients to facilitate the consistent use of outcomes in trials and enhance the translation of research findings into clinical practice.
The landscape of gastro-oesophageal adenocarcinoma (GEA) management has undergone substantial transformation over the past decade owing to shifts in epidemiology, evolving treatment paradigms and the integration of new therapeutic strategies. The global burden of GEA continues to rise, with differing patterns observed in Asia compared with Western countries. Important insights gleaned from recent high-profile clinical trials - both successful and negative - have considerably reshaped perioperative treatment strategies, redefining the roles of chemotherapy, radiotherapy, immune checkpoint inhibitors and targeted therapies. Although still investigational, organ-preserving approaches and circulating tumour DNA (ctDNA)-based patient stratification are shaping the direction of future GEA management. By consolidating these developments, this Review aims to provide clinicians and researchers with a comprehensive and structured guide to the state-of-the-art perioperative management of GEA, emphasizing the underlying biology, clinical implications and future directions.
Objective: To investigate the feasibility and safety of interventional embolization combined with robotic surgery for adrenal pheochromocytoma. Methods: A retrospective analysis was conducted on clinical data from three patients with adrenal pheochromocytoma who underwent interventional embolization combined with robotic surgery at Tianjin First Central Hospital from June 2022 to March 2024. All patients underwent preoperative adrenal artery embolization followed by robot-assisted laparoscopic adrenalectomy. Clinical data including operative time, intraoperative blood loss, postoperative drainage tube duration, postoperative hospital stay, pathological findings, and follow-up results were collected. Focusing on its impact on maintaining perioperative (particularly intraoperative) hemodynamic stability, and to evaluate its effect on reducing intraoperative blood loss. Results: Among the three patients, one was male and two were female, with ages of 50, 76, and 46 years, respectively. Pheochromocytomas were located on the left side in two cases and on the right side in one case. The maximum tumor diameters were 6.0 cm, 6.2 cm, and 5.8 cm, respectively. All three procedures were successful without conversion to open surgery. The operative times were 117, 181, and 127 minutes, respectively. Intraoperative blood loss was 100 ml, 50 ml, and 30 ml, respectively, with no intraoperative blood transfusion required. Postoperative drainage tube durations were 4, 4, and 3 days, respectively. Postoperative hospital stays were 7, 6, and 6 days, respectively. One patient experienced a hypertensive episode after embolization, while the other two experienced hypertensive episodes during embolization, all of which were controlled with medication. During robotic surgery, all three patients maintained stable blood pressure, and no other surgery-related complications were observed. Complete resection of the adrenal tumors was achieved in all cases. During robotic surgery, a significant reduction in adrenal blood supply was noted. Postoperatively, two patients developed hypotension, which stabilized after norepinephrine infusion. Follow-up ranged from 10 to 30 months, with a median follow-up of 22 months. All patients maintained stable blood pressure levels, with no tumor recurrence or complications observed. Conclusions: Preoperative interventional embolization combined with robot-assisted surgery for pheochromocytoma is safe and feasible. It contributes to maintaining intraoperative hemodynamic stability while reducing tumor blood supply, thereby decreasing perioperative blood loss and potentially lowering surgical difficulty. 目的： 探讨介入栓塞联合机器人手术治疗肾上腺嗜铬细胞瘤的可行性及安全性。 方法： 回顾性分析2022年6月至2024年3月于天津市第一中心医院行介入栓塞联合机器人手术治疗肾上腺嗜铬细胞瘤患者（3例）的临床资料。所有患者均于术前行肾上腺动脉栓塞后行机器人辅助腹腔镜肾上腺切除术，收集手术时间、术中出血量、术后引流管放置时间、术后住院时间、病理结果和随访结果等临床资料。重点评估其对维持围手术期（特别是术中）血流动力学稳定性的影响，并评估其对减少术中出血的效果。 结果： 3例患者中，男1例，女2例；年龄分别为50、76、46岁；嗜铬细胞瘤位于左侧2例，右侧1例；肿瘤最大径分别为6.0、6.2、5.8 cm。3例手术均获成功，无中转开放情况。手术时间分别为117、181、127 min。术中出血量分别为100、50、30 ml，术中均未输血。术后引流管放置时间分别为4、4、3 d。术后住院时间分别为7、6、6 d。1例患者于栓塞后出现高血压发作，另2例于栓塞过程中出现高血压发作，给予药物后均可控制。3例患者在机器人手术中血压均较平稳，未发现与手术相关的其他并发症。3例患者肾上腺肿瘤均被完全切除。在机器人手术中均发现肾上腺血供显著减少。术后2例患者出现血压下降，泵入去甲肾上腺素血压稳定。随访10～30个月，中位随访时间为22个月，全部患者血压水平控制稳定，均未见肿瘤复发及并发症发生。 结论： 术前介入栓塞联合机器人辅助手术治疗嗜铬细胞瘤是安全、可行的，有利于维持术中血流动力学的稳定，同时减少肿瘤血供，从而减少围手术期出血量，可能会降低手术难度。.
Enhanced Recovery After Surgery programmes combine efficient perioperative care pathways with evidence-based strategies to improve physiological readiness for surgery. In total, 220 patients undergoing laparoscopic sleeve gastrectomies in 2018 (pre-Enhanced Recovery After Surgery) were retrospectively compared with 143 patients undergoing laparoscopic sleeve gastrectomies in 2023-24 (Enhanced Recovery After Surgery) at our institution. Comparisons looked at postoperative length of stay, post-anaesthesia care unit length of stay, opioid usage, postoperative nausea and vomiting, visual analogue pain scores, 30-day readmissions, and mortality rates. The primary goal of this study was to evaluate the association between implementation of our Enhanced Recovery After Surgery protocol at year 5 with postoperative outcomes, with a focus on patient length of stay and opioid usage. Our protocol saw a significant decrease in all variables, with similar readmissions and mortality rates. The bariatric Enhanced Recovery After Surgery protocol implemented at our institution for laparoscopic sleeve gastrectomy improved perioperative outcomes with no increased patient risk.
Total knee arthroplasty (TKA) is a widely performed procedure for end-stage knee osteoarthritis, with anaesthesia techniques evolving significantly in recent decades. This retrospective study examines trends in anaesthetic practice and postoperative outcomes at an Australian tertiary hospital network, using Acute Pain Service (APS) data from two distinct time periods (1999-2004 and 2018-2022). Elective TKA patients enrolled in the acute pain service database from January 1999 to December 2004 (Cohort 1) and January 2018 to December 2022 (Cohort 2) were included. Baseline demographics and anaesthetic practices were compared descriptively. Postoperative outcomes were analysed using mixed-effects regression models adjusted for demographic and perioperative factors, with hospital included as a random effect. Outcomes included invasive pain management strategies, opioid consumption, pain scores, time to mobilisation, APS review duration and length of hospital stay. A total of 1273 patients were included (150 in Cohort 1 and 1123 in Cohort 2). Use of spinal anaesthesia increased significantly in Cohort 2 compared with Cohort 1 (96.4% versus 24.0%, p < 0.001), as did the adoption of regional anaesthesia techniques (74.3% versus 1.3%, p < 0.001). After adjustment, patients in Cohort 2 had significantly lower odds of requiring invasive pain management strategies (OR: 0.02 and 95% CI: 0.00-0.09; p < 0.001), mobilised earlier (β: -0.39 days, p = 0.009), required fewer days of APS review (β: -0.59 days, p < 0.001) and had shorter hospital stays (β: -2.44 days, p = 0.001). However, postoperative day one opioid consumption was higher in Cohort 2 (β: 55.19 mg oral morphine equivalents, p < 0.001), and movement-related pain scores were modestly increased (β: 1.00, p = 0.02). Resting pain scores and opioid-related side effects were comparable between cohorts. Over two decades, anaesthetic practice for TKA has shifted substantially toward neuraxial and motor-sparing regional techniques. These changes were independently associated with earlier mobilisation, reduced reliance on invasive pain strategies and shorter hospitalisation, despite higher early postoperative opioid use. The findings reflect evolving international practice patterns and highlight the importance of ongoing evaluation of perioperative care pathways.
Advances in neurosurgical techniques and perioperative management have improved survival and neurological outcomes in several neurosurgical diseases. Nonetheless, even when objective functional scales, such as the modified Rankin Scale or Karnofsky Performance Status, indicate favorable outcomes, patients may experience persistent impairments in quality of life (QOL) and higher brain function, affecting daily activities, social participation, and treatment satisfaction. Conventional neurological examinations and imaging often fail to capture subtle cognitive, emotional, and psychosocial difficulties. Moreover, patient-reported outcomes and health-related QOL assessments provide a complementary perspective that reflects patients'subjective experiences, including fatigue, attention deficits, anxiety, and depressive symptoms. This review outlines a practical framework for incorporating QOL and higher brain function assessments into routine neurosurgical practice. Appropriate timing for preoperative and postoperative evaluations, commonly used general and disease-specific QOL instruments, and brief cognitive screening tools applicable in busy clinical settings are discussed. Notably, emphasis is placed on stepwise assessment strategies and multidisciplinary collaboration due to limited manpower. Integrating objective functional measures with patient-centered QOL evaluations enables a more comprehensive understanding of treatment outcomes and supports individualized clinical decision-making aimed at optimizing long-term patient well-being.
Checkpoint inhibitor (CPI) therapy has emerged as treatment option in selected patients with resectable head and neck squamous cell carcinoma. Recent phase III data have led to approval of perioperative pembrolizumab for patients with PD-L1-positive (CPS ≥ 1). With emerging data on adjuvant checkpoint inhibitor therapy the selection of the optimal treatment strategy is becoming increasingly complex. Several clinical phase II/III trials have evaluated neoadjuvant immunotherapy in resectable head and neck cancer, demonstrating both clinical and immunological benefits. This review summarizes current data on neoadjuvant and perioperative checkpoint inhibitors in resectable head and neck cancer and addresses main immunological advantages. In addition, potential strategies to optimize treatment efficacy and to overcome resistance mechanisms of CPI therapy are discussed. Further trials are needed to define optimal treatment protocols, determinate the best timing of surgery, and identify reliable biomarkers for patient selection, to guide evidence-based therapeutic decision-making in routine clinical practice.
Psychological adjustment to amputation begins well before surgery and is pivotal in determining both functional and emotional outcomes. For patients with Peripheral Arterial Disease (PAD), understanding their emotional and psychological challenges during the perioperative period is essential for healthcare teams to provide effective support. Addressing these challenges can enhance surgical outcomes and facilitate long-term rehabilitation. As patients approach amputation, their psychological adjustment significantly influences postoperative recovery and quality of life. Surgeons and healthcare teams should integrate psychological considerations into care planning to optimize outcomes and support holistic healing. This study explores the psychological challenges faced by patients with PAD undergoing amputation, providing insights relevant to surgeons in enhancing preoperative care. We conducted a qualitative study with patients who underwent primary elective amputations as part of a vascular surgery inpatient service. Data was collected through semi-structured interviews, which were conducted between five and ten days post-amputation. The interviews were analyzed using Braun and Clarke's (2006) guidelines for thematic analysis, which allowed for the identification of key patterns and themes related to the psychological adjustment process. Three key themes emerged: Breaking Point, diminished quality of life threshold when patients reached a threshold of suffering from PAD; Meaning Attributed to Amputation, highlighting varied perceptions of the procedure's impact on quality of life; and Trust in the Healthcare Team, emphasizing the role of effective communication and trust in the patient-provider relationship. These findings underscore the importance of addressing emotional and psychological needs of patients in the preoperative period to improve surgical outcomes. By fostering trust, and providing tailored preoperative support, surgeons along with the healthcare team can help better prepare patients to enhance post-operative recovery and reduce anxiety, and negative cognitions. Future research should explore practical effective ways to integrate psychological care into surgical practice, with a focus on improving both emotional and functional outcomes.
Enhanced Recovery After Surgery (ERAS) programmes improve perioperative outcomes, but real-world adherence varies widely across institutions, limiting their effectiveness. Disease-Specific Care Certification (DSCC) provides governance and standardisation but lacks operational mechanisms for frontline implementation. This study evaluates an integrated Quality Control Circle (QCC) model aligned with DSCC and ERAS protocols to improve perioperative reliability and patient-centred outcomes in joint replacement. A pre-post quasi-experimental study was conducted involving 515 patients undergoing elective total joint replacement. A multidisciplinary QCC team employed root-cause analysis, Pareto prioritisation and iterative Plan-Do-Study-Act cycles to refine processes. DSCC governance principles were used to structure standardised pathways, unify documentation and reinforce interdisciplinary communication. Outcomes included ERAS compliance, length of stay (LOS), preoperative discomfort (thirst, dry mouth), unnecessary blood preparation, complications and staff competency. ERAS compliance increased from 80.9% to 100% after implementation. Preoperative thirst (p=0.0156) and dry mouth scores (p=0.0073) improved significantly. LOS decreased from 6.63 to 5.98 days. Unnecessary blood preparation was reduced from 237 units to zero. Staff competency improved across all domains. No increase in postoperative complications or readmissions was observed. Integration of QCC operational tools, DSCC governance and ERAS clinical elements yielded substantial improvements in perioperative reliability, efficiency and patient comfort. The QCC-DSCC-ERAS hybrid model is feasible, scalable and potentially generalisable to other institutions seeking high-reliability perioperative care.
To evaluate whether perioperative nutritional intervention guided jointly by Nutritional Risk Screening 2002 (NRS 2002) and the Global Leadership Initiative on Malnutrition (GLIM) improves nutritional status, postoperative complications, and quality of life in patients undergoing intracranial tumor surgery. This non-randomized controlled study enrolled 120 adult patients who underwent intracranial tumor surgery in the Department of Neurosurgery of a tertiary hospital between January 2021 and June 2024. Patients admitted from January 2021 to December 2022 received conventional perioperative nursing care (control group, n = 60), whereas those admitted from January 2023 to June 2024 received individualized nutritional intervention guided by NRS 2002 and GLIM (intervention group, n = 60). The intervention incorporated local dietary practices and included dynamic preoperative nutritional monitoring, targeted protein supplementation, postoperative oral nutritional supplementation, and stepwise dietary transition management. Outcomes included postoperative nutritional indicators, nursing-related complications, length of stay, and quality of life. At 1 month after surgery, the intervention group demonstrated significantly better nutritional indicators than the control group, including hemoglobin (128.5 ± 10.88 g/L), albumin (39.04 ± 6.25 g/L), and prealbumin (196.83 ± 21.30 mg/L) (all P < 0.05). The overall complication rate was significantly lower in the intervention group than in the control group (1.7% vs. 40.0%, P < 0.05). At 3 months after surgery, patients in the intervention group had significantly higher scores for physical, emotional, cognitive, and social functioning, as well as global health status, and significantly lower symptom scores than those in the control group (all P < 0.05). Nutritional status was negatively correlated with functional quality-of-life domains (r = -0.636 to -0.363, all P < 0.05) and positively correlated with symptom burden (r = 0.256-0.778, all P < 0.05). The intervention group also had a shorter postoperative hospital stay. Perioperative nutritional intervention guided by NRS 2002 and GLIM may optimize nutritional status, reduce postoperative complications, and improve postoperative recovery in patients undergoing intracranial tumor surgery. This approach appears clinically applicable in neurosurgical practice and merits further evaluation in multicenter randomized studies. Funding This study was supported by the Scientific Research Project of the Qinghai Provincial Health Commission (No. 2020-wjzdx-16).
Widespread adoption of artificial intelligence into surgical care heavily depends on clinician and patient attitudes, which remain poorly characterized. This scoping review aimed to synthesize existing literature on clinician and patient perspectives toward the use of artificial intelligence in perioperative settings and to identify reported barriers and facilitators to its integration. A scoping review of MEDLINE, EMBASE, PubMed, CINAHL, and Web of Science was conducted for studies published up to June 2024 that reported surgeon or patient perspectives on artificial intelligence use in surgical care. Findings were qualitatively analyzed and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis scoping review guidelines. Two thousand one hundred fifty-eight records were screened, and 16 studies met inclusion criteria. Four themes emerged: (1) familiarity with artificial intelligence, (2) confidence and trust, (3) expectations for use, and (4) ethical concerns and liability. Surgeons and patients acknowledged potential benefits of artificial intelligence, particularly in preoperative decision-making. Trust was greater when artificial intelligence functioned as a decision-support tool rather than an autonomous system. As artificial intelligence systems became more autonomous, comfort levels declined. Limited understanding of artificial intelligence concepts was reported, alongside concerns regarding transparency, reliability, data privacy, and legislative responsibilities. Successful integration of artificial intelligence into surgical practice requires education for both clinicians and patients, development of transparent and interpretable systems, and clear governance frameworks addressing consent, privacy, and liability. Incorporating stakeholder perspectives during artificial intelligence development may help facilitate ethical, patient-centered adoption in perioperative care.
Preoperative anxiety is a common distressing phenomenon that negatively affects surgical outcomes and postoperative recovery. This narrative review synthesised evidence on effectiveness of non-pharmacological interventions in managing preoperative anxiety. A structured literature search was conducted across PubMed, Hinari Research4Life, Cochrane Library, and Directory of Open Access Journals, focusing on studies evaluating non-pharmacological interventions in surgical patients, published within the last 5 years. Out of 359 total records identified, only 24 studies met inclusion criteria following structured screening process using Scale for the Assessment of Narrative Review Articles guidelines. The findings suggest that various psychological interventions, including virtual reality, music therapy, mindfulness-based approaches, and cognitive-behavioural techniques, are associated with reductions in preoperative anxiety in several patient populations. These interventions offer non-invasive and potentially accessible means of improving perioperative care in well-resourced settings. However, variability in study design, intervention protocols, and outcome measures limits direct comparison across studies. As a narrative synthesis, the findings should be interpreted with consideration of these methodological differences. Non-pharmacological interventions, particularly virtual reality and mindfulness, are effective alternatives/adjuncts to pharmacological methods for reducing preoperative anxiety. However, heterogeneity of interventions and outcome measures limits generalisability. Future research should include large-scale randomised controlled trials, standardisation of outcome measures, and culturally adapted studies in different populations.