The co-occurrence of mirror-image dextrocardia and tetralogy of Fallot (TOF) is a rare congenital condition. Reoperative multivalve surgery in such patients, especially after repaired TOF, presents exceptional challenges due to the mirrored cardiac anatomy and altered surgical field. This case highlights the surgical strategy for concomitant tricuspid, mitral, and pulmonary valve replacement in this unique setting. A 14-year-old male patient with a history of corrected TOF and mirror-image dextrocardia presented with progressive heart failure due to severe regurgitation of the tricuspid, mitral, and pulmonary valves. Preoperative imaging confirmed the complex anatomy, with the atria positioned posteriorly, rendering the atrioventricular valve orifices near-vertical during surgery. The patient successfully underwent triple valve replacement under cardiopulmonary bypass. Key technical adaptations were made to select the valve model and position. The postoperative course was uneventful, with significant symptomatic and echocardiographic improvement at discharge and during the two-month and six-month follow-up. This case demonstrates that concomitant triple valve replacement is feasible in patients with mirror-image dextrocardia and a history of TOF repair, despite the profound technical challenges posed by the anatomical distortions. Success hinges on meticulous preoperative planning using advanced imaging and the development of an individualized surgical approach. This report provides a valuable reference for managing such complex, high-risk reoperations in the setting of congenital situs inversus.
SMARCB1-deficient sinonasal carcinoma (SDSC) is a rare, highly aggressive malignancy with limited therapeutic options and no established preclinical models. Here, single-nucleus RNA sequencing (snRNAseq), spatial transcriptomics, and ex vivo patient-derived tissue slice culture (TSC) were combined to resolve intratumoral heterogeneity, niche organization, and treatment vulnerabilities in an index SDSC. snRNAseq identified three malignant subpopulations, including two specialized states marked by ALDH1A1 and NTN4. Spatial profiling mapped these states to distinct niches. The ALDH1A1+ compartment localized to a basal-associated niche with intermingled p63-positive basal cells adjacent to stroma, showed reduced proliferative activity, and displayed stem-like transcriptional features. Ex vivo drug testing revealed a striking response: the mTOR inhibitor Sapanisertib induced extensive tumor necrosis and was associated with near-complete depletion of ALDH1A1+ and NTN4+ states, accompanied by strong stress/apoptosis signatures and reduced endothelial cells. In an additional retrospective cohort of 12 SDSC, ALDH1A1 was present in all cases with heterogeneous spatial patterns and higher levels in recurrences. Mesothelin was expressed in the index case and a subset of tumors, supporting mesothelin-directed therapeutic strategies.
Aiming at the control problems of strong nonlinearity, multi-channel coupling and complex aerodynamic disturbance of flapping-wing aircraft, this study proposes an environment-adaptive cascade control switching method based on the PID architecture. A physical control closed-loop is established using MWORKS.Sysplorer, with classical PID as the outer main loop and PID, nonlinear compensation PID, and SMC as the inner loop to form a nested structure, which is cross-validated via MATLAB/Simulink. Through the disturbance quantization parameter k, operating conditions are classified into high, medium, and low disturbances for strategy switching. At the classical flapping frequency of 15 Hz, the proposed method converges the attitude error to within 0.06 rad, improves the anti-disturbance performance under high disturbance by 46.2% compared with traditional PID, constrains the phase lag to the stable interval corresponding to the natural frequency of 50 rad/s, and optimizes computational efficiency with the average single-step simulation time ≤ 0.02 s. This method addresses the insufficient full-working-condition adaptability of traditional single control strategies, and provides a highly robust implementation approach for the control of flapping-wing aircraft under complex disturbances.
Limb salvage centers have increased in number over time, but lack standardized defining criteria. This systematic review aimed to assess organizational features of limb salvage centers and determine whether orthoplastic centers, in comparison to vascular limb salvage centers, represent a distinct care model that may benefit from standardization. We conducted a systematic review of publications related to limb salvage centers by searching MEDLINE, Embase, Web of Science, and Cochrane databases from their inception through 2024. We quantified binary data extraction as a reporting score of 26 organizational features across six structural care domains for limb salvage centers, based on a validated quality measurement framework. Organizational features differentiating distinct center types were identified to establish a quality framework for orthoplastic centers. Statistical comparisons between center types were performed using appropriate tests (p < 0.05). Of 118 included studies, orthoplastic (n = 43) and vascular (n = 48) centers represented 77% of all studies. Recent increases in orthoplastic publications show substantial variability in organizational features. Orthoplastic center literature more frequently reported plastic surgery consultation criteria (p < 0.001), surgical outcomes (p < 0.001), and centralized network integration (p ≤ 0.006), highlighting acute reconstructive approaches. Vascular center studies documented significantly more organizational team features (p < 0.001) and quality systems (p = 0.033), reflecting established care frameworks for chronic disease management. Six organizational features characterized orthoplastic centers with > 70% prevalence, providing a benchmark framework with standardization priorities. Orthoplastic limb salvage centers demonstrate distinct care paradigms that benefit from standardization. Our findings suggest structural benchmarks to support the need for standardized development of orthoplastic limb salvage centers.
Home environments shape children's dietary habits, but which factors are most influential is unclear. The study purpose was to identify factors in the home environment associated with child intake of fruit and vegetables (FV) and sugar-sweetened beverages (SSBs) using a national dataset collected in 2013-2015 in the U.S. Data from 5,138 school-aged children (4-15 years old) from 130 U.S. communities were collected in 2013-2015. Parents and/or children completed a dietary screener and additional survey questions to assess household socioeconomic status (SES), grocery shopping sources, home food availability, social support for healthy eating, eating out frequency, and other home eating and related behaviors. Other child characteristics included breastfeeding history, intake of school foods, and participation in other nutrition programs. Community variables included predominant race/ethnicity and SES. Classification and regression trees (CART) identified key predictors of intake. The FV and SSB CARTS had 14 and 12 terminal groups, respectively. Children with the highest FV intake (0.54 SD from mean cups/day; 13% of sample) had fruit more often available at home, dark green vegetables more often available at home, ate dinner with family more often, had SSBs less often available at home, and were breastfed longer. Conversely, children in the two groups with the lowest FV intake either had fruit less often available at home, and family never complimented their eating (-0.86; 2%), or they had family that rarely or sometimes complimented their eating, and perceived school lunches as unhealthy (-0.87; 1%). For SSB intake, the lowest consumers (-0.63 SD from mean tsp/day sugar; 17%) never or rarely had SSBs available at home, and lived in higher SES communities. Children in the two groups with the highest SSB intakes had SSBs available at home more often, and lived in a SNAP-participating household and either ate out less often, used a phone/computer for social networking, and had SSBs available at home very often (1.3; 1%), or they ate out more often, and were breastfed for a shorter duration (1.1; 5%). Home availability of FV and SSBs were the most salient predictors of intake of both FV and SSBs, while other predictors differed between FV and SSB intake. Study findings highlight several actionable home-environment strategies to test in future studies to improve school-aged children's diets.
Neuropathic pain caused by spinal cord injury severely compromises patients' quality of life. The clinical application of ropivacaine is limited by its short duration of action and the significant side effects associated with repeated administration. In this study, we developed a Gelatin methacryloyl/hyaluronic acid-based hydrogel (Ropi-GelMA/HA) to enable localized and controlled delivery of ropivacaine by photo-crosslinking. In a rat model of spinal cord contusion, Ropi-GelMA/HA was associated with lower Nav1.3 and TNF-α expression and higher NGF and BDNF expression, together with improved motor recovery in rats with SCI. In vitro studies further supported the hydrogel's favorable biocompatibility and controlled release behavior during the early phase after administration. Under the tested dosing regimens, Ropi-GelMA/HA was associated with reduced hepatorenal toxicity and more durable analgesic efficacy compared with free ropivacaine, resulting in prolonged analgesic effects and improved functional outcomes under localized controlled delivery conditions. These findings highlight the potential clinical utility of Ropi-GelMA/HA in the treatment of neuropathic pain following spinal cord injury.
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are severe complications following hemorrhagic shock, leading to significant morbidity and mortality. Direct peritoneal resuscitation (DPR) has been proposed to improve microcirculation and reduce organ damage, but its effects on lung injury have not yet been fully explored. Does direct peritoneal resuscitation with peritoneal dialysis fluid (PDF) reduce lung injury in a controlled hemorrhagic shock model in rats? In this randomized experimental study, 32 male Wistar albino rats were randomly assigned to four groups (n = 8 per group). Group I served as the control group, while Groups II, III, and IV underwent hemorrhagic shock. Group III received peritoneal resuscitation with saline, and Group IV received PDF. Lung tissue samples were harvested after 24 h to assess histopathological damage and inflammatory markers; Interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-alpha (TNF-α) levels. DPR with PDF significantly attenuated lung injury compared to saline-treated or hemorrhagic shock-only groups. Interstitial polymorphonuclear leukocytes (PMNL) infiltration and alveolar septal thickening were reduced in the DPR group. Additionally, IL-6 levels were elevated in the DPR group, suggesting a potentially enhanced localized inflammatory response, while no significant differences were found in IL-10 and TNF-α levels. Direct peritoneal resuscitation with PDF was effective in reducing lung injury in rats subjected to hemorrhagic shock by improving microcirculatory function and modulating the inflammatory response. However, the elevated IL-6 levels suggest further investigation is needed to understand the long-term implications of this inflammatory response.
Light pollution has been implicated in liver health. This study aimed to investigate the association between bedroom nighttime light pollution and the risk of hepatic encephalopathy (HE) in patients with hepatocellular carcinoma (HCC). A total of 454 HCC patients were enrolled from communities. Bedroom nighttime light intensity was measured using an illuminometer (lux) at baseline, 2 months, and 4 months. Sleep quality was assessed at these three time points using the Pittsburgh Sleep Quality Index. These data at different time points were averaged separately for subsequent analyses. All patients were followed up for 12 months from baseline (unless death occurred), and HCC-related adverse outcomes were recorded. Multivariate logistic and Cox regression were adopted for statistical analysis. The results indicated that higher mean bedroom nighttime light intensity (> 50 lx) was significantly associated with an increased risk of both overt HE and minimal HE. Furthermore, it was associated with impaired liver function, esophagogastric variceal bleeding, and elevated HCC-related mortality. Notably, interaction analysis revealed that age and TNM stage may modify the aforementioned associations to some extent. In conclusion, bedroom nighttime light pollution is linked to an elevated risk of HE and may represent a potential risk factor warranting future validation.
Proximal femoral fractures are highly prevalent in Japan, with over 200,000 cases annually and a rising trend. Fracture liaison service (FLS) interventions improve osteoporosis treatment initiation and reduce refracture rates. The content of FLS interventions varies by institution, and the effectiveness of our intervention remains unclear. The aim of this study was to evaluate the effectiveness of our FLS intervention in preventing fragility fractures within 1 year after proximal femoral fracture surgery. A retrospective case-control study was performed on patients aged ≥ 50 undergoing surgery for proximal femoral fracture between February 2021 and January 2024. Patients were divided into non-FLS (pre-August 2022) and FLS groups. Data including demographics, comorbidities, fracture type, medication initiation, and refracture occurrence within 1 year were extracted. Statistical analyses involved Mann-Whitney U, χ2 tests, and Cox proportional hazards modeling. Among 521 eligible patients, osteoporosis medication initiation within 3 months improved from 14% in the non-FLS group to 100% in the FLS group (p < 0.05). Time to medication initiation decreased from 20 to 12 days (p < 0.05). The refracture rate was significantly lower in the FLS group (1.8% vs. 5.7%, p < 0.05). Multivariate analysis showed FLS intervention significantly reduced refracture risk (HR 0.32, 95% CI 0.12-0.89, p = 0.03) and robust in sensitivity analyses for cognition, walking ability, and discharge destination. FLS intervention effectively reduced fragility fractures within 1 year postoperatively by enhancing early osteoporosis treatment initiation. Continued FLS programs and long-term follow-up are recommended to sustain benefits.
A history of prior cardiac surgery (PCS) determines treatment decision and long-term outcomes in patients requiring aortic valve replacement. This study examined patient profiles, treatment-decisions and long-term outcomes of patients under 75 years with PCS undergoing transcatheter and surgical aortic valve implantation/replacement (TAVI, SAVR) in the Netherlands. Data from 1,284 patients (ages 50-75 years) with PCS undergoing TAVI or SAVR between 2015 and 2020 were analyzed using data from the Netherlands Heart Registration. Logistic and cox regression identified determinants of treatment selection and long-term mortality. Determinants were considered impactful if they had an odds ratio (OR) or hazard ratio (HR) of ≥ 1.5 or ≤ 0.7 and a prevalence of ≥ 5%. Of 1,284 patients, 690 underwent TAVI (54%) and 594 SAVR (46%). Prior index surgery most frequently involved coronary artery bypass grafting (CABG) (57% in the TAVI group vs 40% in the SAVR group; p < 0.001) and previous aortic valve surgery (25% vs 51%; p < 0.001). TAVI patients were significantly older (median 71 vs. 67 years, p < 0.001) and had a higher EuroSCORE II (median 5.7 vs. 4.4, p = 0.003) than SAVR patients. SAVR was the preferred strategy for intermediate-risk patients (62%), while TAVI was favored in high- and prohibitive-risk patients (62% and 94%, respectively). In descending order of odds ratio, the strongest independent determinants of TAVI selection were left ventricular ejection fraction ≤ 30% ((OR: 4.8; 95% CI: 2.6-8.8), poor mobility ((OR: 3.4; 95% CI: 1.6-7.0) and obesity/cachexia (OR 2.7; 95% CI: 1.6-4.4); the key determinants of SAVR selection were pure native aortic regurgitation (OR: 0.1; 95% CI: 0.1-0.3) and failing surgical bioprosthesis (OR: 0.7; 95% CI: 0.5-1.0. Thirty-day, 1- and 5 year survival after TAVI and SAVR was 97% and 96%, 83% and 91%, and 56% and 83%, respectively (p-value < 0.001). Left ventricular ejection fraction ≤ 30% and chronic lung disease were important mortality determinants for both procedures, with higher odds ratios for mortality in SAVR as compared to in TAVI patients. In the Netherlands, TAVI and SAVR rates were comparable among patients < 75 years with PCS. Higher-risk patients were directed toward TAVI except for those presenting with pure native aortic regurgitation and bioprosthesis failure who mainly received SAVR. Severe left ventricular dysfunction and chronic lung disease were key mortality predictors for both procedures.
Hydatid cyst disease is a parasitic disease induced by Echinococcus granulosus, which is still endemic in northern African countries. We report the case of a late-discovered pulmonary hydatid cyst in a four-year-old boy revealed by recent dyspnoea. The chest X-ray showed a complete white-out of the left hemithorax with mediastinal deviation, and the thoracoabdominal CT scan showed a giant pulmonary hydatid cyst encompassing the entire left lung associated with a hepatic cyst. An emergent superior pulmonary lobe resection was performed under deep general anaesthesia and selective intubation to prevent contralateral lung inundation. The evolution was favourable postoperatively.
Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal tumors composed of cells exhibiting an epithelioid morphology. These cells typically arrange around small blood vessels (perivascular spaces) and display dual differentiation characteristics of smooth muscle cells and melanocytes. Diagnosis is challenging due to the absence of specific symptoms or tumor markers. This case features a young male patient with a large hepatic PEComa, whose imaging findings resemble those of hepatocellular carcinoma. We have detailed the entire process from diagnosis to treatment to aid in differential diagnosis and surgical planning. A 31-year-old male patient with no prior medical history underwent a routine health examination 20 days prior to presentation. Although the patient was asymptomatic, ultrasound revealed an incidental hepatic lesion measuring 58 × 50 × 45 mm (maximum diameter 58 mm, or 5.8 cm). The screening center suspected a hemangioma. Subsequently, he presented to our hospital. Comprehensive imaging studies, including ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), revealed a 58 mm-diameter space-occupying lesion in segments V and VIII of the right hepatic lobe. Imaging findings initially raised suspicion for hepatocellular carcinoma. To minimize surgical trauma and preserve liver function, our team discussed surgical approaches and ultimately decided on a laparoscopic partial hepatectomy. During the procedure, we obtained a specimen for pathological examination. The final histopathological analysis confirmed the diagnosis of a PEComa with undetermined malignant potential. The patient recovered smoothly postoperatively and was successfully discharged. PEComa has an insidious onset and is rare. Early diagnosis is often challenging, and imaging studies typically show no highly specific findings. Clinical diagnosis frequently relies on biopsy. In terms of treatment, radical resection (R0 resection, i.e., negative margins) represents the definitive therapeutic approach.
Acetabular fractures are uncommon, but serious injuries. Demographic changes may have a significant impact on planning healthcare structures to improve treatment outcomes. Aim of this nationwide, registry-based retrospective controlled study was to identify incidence trends, demographic characteristics, and care structures of patients with acetabular fractures in Germany. We analyzed inpatient data from the Institute for the Hospital Remuneration System (InEK). Based on 52 095 patients with primary diagnosis of an acetabular fracture between 2019 and 2024, we calculated incidence rates for different age-groups and put a spotlight on geriatric acetabular fractures (> 65 years of age). Incidence rates in patients under 65 years remained stable, whereas patients over 65 years showed a significant age-dependent increase with an exponential rise in men aged 80 + with the highest incidence being 122.4/100 000 inhabitants annually. We recorded high levels of co-morbidity and nursing care dependency for elderly patients after acetabular fracture. Although 43% of patients were treated in hospitals > 500 beds, acetabular fractures were managed across all hospital sizes. There is a rapidly increasing incidence of geriatric acetabular fractures, predominantly driven by elderly male patients over 80 years. Patients over 65 years are associated with high rates of co-morbidities and nursing care levels.
Achondroplasia (ACH) is the most common skeletal dysplasia characterized by disproportionate short stature due to impaired endochondral ossification. One of the most critical and potentially fatal complications of ACH is foramen magnum and upper cervical canal stenosis. Compression at the cervicomedullary junction may lead to myelopathy, hypotonia, developmental delay, and central sleep apnea. Early detection and timely surgical intervention are essential to prevent permanent neurological injury. This retrospective study evaluated 15 pediatric patients with ACH (9 girls, 6 boys; age range 3-42 months, mean 17.2 months) who underwent foramen magnum decompression and C1 laminectomy at Marmara University Neurosurgery Department between 2016 and 2025. All patients underwent comprehensive neurological and radiological evaluation, including MRI and 3D CT of the craniovertebral junction, and were classified by the Achondroplasia Foramen Magnum Score (AFMS). Nine patients had AFMS level 4 stenosis and six had level 3. The anteroposterior diameter of the foramen magnum ranged from 4.03 to 11.03 mm, with an area between 17.40 and 105.16 mm2. Presenting symptoms included motor delay (n = 4), respiratory disturbances or central apnea (n = 4), and macrocephaly (n = 3). Postoperative imaging confirmed adequate decompression in all patients. Neurological and respiratory improvement occurred in all patients except one with persistent hypotonia. One patient died early postoperatively due to recurrent pneumonia and sepsis. Complications were minimal. Foramen magnum decompression with C1 laminectomy is a safe and effective procedure for infants and children with achondroplasia presenting with cervicomedullary compression. Early radiological and neurological evaluation, particularly with AFMS, facilitates accurate surgical decision-making and improves outcomes.
Pediatric femoral neck fractures require stable fixation to avoid complications. It remains unclear whether fixation with the Proximal Humeral Internal Locking System (PHILOS) can serve as an alternative to cannulated screw fixation. The purpose of this study was to compare the biomechanical properties of PHILOS and cannulated screws for stabilizing unstable pediatric femoral neck fractures using a synthetic bone model. Twelve fourth-generation synthetic composite femurs were randomly assigned to screw fixation (Group S) or PHILOS fixation (Group P) (n = 6 each). A standardized vertically oriented Delbet type II osteotomy was created in all specimens. Group S was fixed with three 6.5-mm cannulated screws, whereas Group P received a PHILOS plate with 3.5-mm locking screws. Each specimen underwent a standardized loading protocol using a universal testing machine. Axial stiffness, cyclic displacement, ultimate failure load, and failure modes were recorded and statistically compared between groups. No statistically significant difference was found in axial stiffness between Group P (746 ± 300 N/mm) and Group S (753 ± 256 N/mm) (p = 1.000). Displacement after cyclic loading was significantly greater in Group P (1.42 ± 0.3 mm) compared with Group S (0.57 ± 0.2 mm) (p = 0.004). The ultimate failure load was higher in Group S (2378 ± 513 N) than it was in Group P (1652 ± 206 N) (p = 0.025). Upon reaching ultimate load, all specimens in both groups failed at the femoral head region due to femoral head broken. The adult PHILOS plate with 3.5-mm locking screws demonstrated inferior biomechanical stability compared with three 6.5-mm cannulated screws in this synthetic composite femur model. Controlled laboratory study.
Effective patient education is critical for informed consent. Augmented Reality (AR) offers a novel approach to improving patient understanding and satisfaction, although current evidence is limited and of low quality. This study evaluated the added value of AR compared to traditional monitor-based 3D models for patient education and decision making for orthognathic surgery. A multicentre randomised controlled trial was conducted between August 2023 and June 2024 at three university medical centres in north-west Europe. Sixty referred patients were randomised to either the intervention group or the control group. Patient satisfaction and knowledge were assessed using two questionnaires. The study was registered at ClinicalTrials.gov(NCT06140043). Patient satisfaction was significantly higher in the control group (p = 0.04). No significant differences were found in knowledge acquisition (p = 0.74). Women showed a significant preference for the monitor-based consultation (p = 0.01), while men did not show a significant difference in satisfaction. Despite some centre heterogeneity, no clear added benefit of AR in satisfaction or knowledge was visible. Observed effect sizes (d = 0.76) and post-hoc power estimates (84%) are provided for context but should be interpreted cautiously. In the absence of clear evidence a monitor remain the most practical option for patient education.
High-risk stage II colorectal cancer (CRC) shows heterogeneous outcomes despite adjuvant chemotherapy. We developed and validated an interpretable multimodal deep learning model integrating clinical data, serum biomarkers, and venous-phase CT to predict 5-year CRC-specific mortality in high-risk stage II CRC. This retrospective, multicenter cohort included 778 high-risk stage II CRC patients from three centers, all treated with adjuvant chemotherapy and with complete preoperative clinical, biomarker, and venous-phase CT data. Patients were split into a development cohort (Centers A + B, n = 720) and an external testing cohort (Center C, n = 58). A multimodal model combining numerical (clinical + biomarker) and imaging (CT) inputs was developed and internally validated using tenfold cross-validation in the development cohort and evaluated in the external cohort. Interpretability was assessed using SHAP and Grad-CAM. In the development cohort, the multimodal model showed superior discrimination (AUC 0.89; 95% CI, 0.87-0.91) versus numerical-only (AUC 0.76) and imaging-only (AUC 0.69). In the external testing cohort (9/58 CRC-specific deaths), the multimodal model achieved an AUC of 0.88 (95% CI, 0.76-0.96). SHAP and Grad-CAM consistently highlighted age, CA125, and tumor regions on CT as key contributors. This interpretable multimodal approach, using routine clinical, biomarker, and CT data, improves 5-year mortality risk stratification in high-risk stage II CRC and may inform risk-adapted surveillance and clinical decision support; prospective validation is warranted before treatment modification.
Central nervous system (CNS) metastases from Wilms tumor (WT) are exceedingly rare. Intracerebral hemorrhage secondary to metastatic WT is even less common, and the management of such cases is further complicated when patients are receiving a direct oral anticoagulant (DOAC) like Rivaroxaban, for which pediatric reversal guidelines are lacking. We report on the case of a 5-year-old boy with relapsed stage IV Wilms tumor who presented with rapidly progressive neurological deterioration caused by brain metastases with extensive intraparenchymal and intraventricular hemorrhage while receiving Rivaroxaban due to prior thrombosis. An emergent craniotomy and tumor resection was safely performed after emergent reversal of anticoagulation with Rivaroxaban using Andexanet alfa, administered in this pediatric patient with off-label consent in the setting of a life-threatening intracranial hemorrhage requiring emergent neurosurgical intervention. No excessive intraoperative bleeding was noted. Treatment for relapsed WT according to the SIOP-UMBRELLA-Protocol was initiated. Three weeks after Andexanet alfa treatment, a thrombotic event in the left iliac veins occurred, requiring anticoagulation with unfractionated heparin. This case highlights the therapeutic challenges of managing intracranial hemorrhage in a pediatric patient requiring emergent neurosurgical debulking in the setting of Rivaroxaban anticoagulation. To our knowledge, this is the second case reporting on Rivaroxaban reversal through Andexanet alfa in children. Early multidisciplinary intervention, meticulous neurosurgical management and continuation of oncologic therapy can lead to favorable outcomes even in such complex presentations.
暂无摘要（点击查看详情）
The association between preoperative peripheral nerve block (PNB), major adverse cardiovascular events (MACE), and postoperative length of hospital stay (LOS) in elderly patients who underwent major thoracic and abdominal surgery remains unclear. This study aims to explore the potential mediating effect of MACE on the association between preoperative PNB and postoperative LOS using a statistical mediation framework. In this retrospective cohort study, perioperative data were collected from elderly patients (aged over 65 years) who underwent major thoracic and abdominal surgery. Mediation analysis was employed to examine the relationships between PNB, MACE, and postoperative LOS. A total of 1915 patients were included in the analysis, with 68.7% (1316/1915) receiving preoperative PNB. Compared to patients who did not receive PNB, those who did had a significantly lower incidence of MACE (P < 0.001) and a shorter postoperative LOS (P < 0.001). The adjusted total and direct associations of PNB with postoperative LOS were - 0.809 days (95% confidence interval [CI], -1.236 to -0.390; P < 0.001) and - 0.661 days (95% CI, -1.077 to -0.250; P = 0.003), respectively. A statistically significant indirect association via MACE was observed (adjusted β=-0.149 days; 95% CI, -0.271 to -0.060; P < 0.001), indicating that 18.1% (95% CI, 6.7% to 41.0%) of the total association was statistically attributable to the indirect pathway through MACE under the model assumptions. A sensitivity analysis excluding postoperative covariates yielded consistent results (proportion mediated: 25.3%). Our findings suggest that the observed association between preoperative PNB and reduced postoperative LOS in elderly patients following major thoracic and abdominal surgery may be partly explained by a statistically significant indirect pathway through a reduction in MACE, potentially accounting for approximately 18% of the total effect. These findings are hypothesis-generating and represent statistical associations rather than demonstrated causal mechanisms. ChiCTR2400087610; https://www.chictr.org.cn.